Jane Maxwell, UT Addiction Research Institute, 512 232-0610 THE GOOD - - PDF document

Jane Maxwell, UT Addiction Research Institute, 512 232-0610

Prescription Pain Medications and Heroin: A Changing Picture

Jane Maxwell, Ph.D. Center for Social Work Research The University of Texas at Austin

Disclosure to Participants Commercial Support: This educational activity received no commercial support. Disclosure of Conflict of Interest The speaker discloses no conflict of interest.

Shifting Between Opiate Pills and Heroin

Pollini et al. found high proportion of young heroin injectors reported problematic prescription–type opioid use before initiating heroin use. NSDUH study from 2002-2011 found 80% who began heroin use in past year (recent initiates) had previous non-medical use of pain relievers. Only 1% of recent initiates reported heroin use prior to using pain relievers.

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Pollini R. et al. Problematic use of prescription type opioids prior to heroin use among young heroin injectors. Sub Abuse and Rehab, 173-180, 2011. Muhuri P. et al. Associations of Nonmedical Pain Reliever Use and Initiation of Heroin Use in the United States. CBMSQ Data Review, SAMHSA, August 2013

Jane Maxwell, UT Addiction Research Institute, 512 232-0610

THE GOOD NEWS & BAD NEWS

• Most shifting from other opiates to heroin.
• Trends in demand, supply, and unintended

consequences heading down (impact of actions by FDA and by manufacturers, and

• verdose campaigns). IDU risks heading up.
• Changes in users (young suburban heroin

users and aging adults dependent on pain pills and benzos).

• Treatment need vs. capacity.
• Unresolved problems in increasing

accessibility to treatment.

Data Sources

• Deaths: CDC Wonder—deaths categorized

by ICD Code

• Treatment: admissions from SAMHSA’s

Treatment Episode Data Set

• Forensic Toxicology Labs: Items identified

in labs which report to DEA’s National Forensic Laboratory System

• Poison center cases: From American

Association of Poison Control Center Annual Reports

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Human Exposure Cases Reported by Poison Centers in the US: AAPCC 2004-2012

5000 10000 15000 20000 25000 30000 35000 2004 2005 2006 2007 2008 2009 2010 2011 2012 # Cases

Hydrocodone Oxycodone Cocaine Methadone Heroin

Annual Reports of the American Association of Poison Control Centers 2004-2012

Jane Maxwell, UT Addiction Research Institute, 512 232-0610

Percentage of Items Identified in DEA’s NFLIS Laboratory System: 2005-2014

2 4 6 8 10 12 14 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 % of Items Seized

Heroin Oxycodone Hydrocodone Methadone

DEA’s National Forensic Laboratory System, data retrieved 9/19/14

Grams of Selected Drugs Distributed per 100,000: DEA ARCOS 1997-2013

100 200 300 400 500 600 700 800 10,000,000 20,000,000 30,000,000 40,000,000 50,000,000 60,000,000 70,000,000

Buprenorphine Hydrocodone, Oxycodone, Methadone

Hydrocodone Methadone Oxycodone Buprenorphine

DEA Automation of Reports and Consolidated Orders System

Number of Drug Poisoning Deaths: United States: CDC 1999—2013

2000 4000 6000 8000 10000 12000 14000 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Other Opiates Methadone Other Synthetics Benzodiazepines Heroin Source: CDC/NCHS WONDER-National Vital Statistics System, Mortality File.

Jane Maxwell, UT Addiction Research Institute, 512 232-0610

Oxycodone

Indicators of oxycodone use based on items distributed by manufacturer, items identified in forensic laboratories, and deaths due to other opiates

50000 100000 150000 200000 250000 20,000,000 40,000,000 60,000,000 80,000,000 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Grams Distributed Tox Labs Deaths Treatment

Source: NFLIS, NCHS, ARCOS, TEDS

Hydrocodone (% of items identified in forensic laboratories and grams distribution by manufacturers)

50000 100000 150000 200000 250000 10,000,000 20,000,000 30,000,000 40,000,000 50,000,000 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Grams Distributed Tox Labs Deaths Treatment

Source: NFLIS,, ARCOS

Heroin

(Deaths, % of Items Identified in NFLIS & Treatment Admissions)

4 8 12 16 20 3000 6000 9000 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Deaths Tox Labs Treatment Source: NFLIS, NCHS, TEDS

Jane Maxwell, UT Addiction Research Institute, 512 232-0610

Methadone

Items Identified in NFLIS, Deaths and ARCOS

4,000,000 8,000,000 12,000,000 16,000,000 20,000,000 2000 4000 6000 8000 10000

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Tox Labs Deaths Grams Distributed

Source: NFLIS, NCHS, ARCOS

Admissions to Treatment Programs by Primary Substance of Abuse: TEDS 1992-2012

11 16 1 9 28 35 60 39

20 40 60 80 100

1992 2012

% of All Admissions Alcohol Other Drugs Other Opiates Heroin SAMHSA Treatment Episode Dataset

47% 84% 70% 90%

0% 20% 40% 60% 80% 100% Heroin Other Opiates & Synthetics

Changes in the Proportion of White Clients Entering Treatment: TEDS 1992-2012

1992 2012

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SAMHSA Treatment Episode Dataset

Jane Maxwell, UT Addiction Research Institute, 512 232-0610

26% 20% 43% 52%

0% 10% 20% 30% 40% 50% 60% Heroin Other Opiates & Synthetics

Proportion of Clients Under Age 30 Entering Treatment: TEDS 1992-2012

1992 2012

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SAMHSA Treatment Episode Dataset

Rates per 100,000 of Drug Poisoning Deaths Involving Heroin in the US: 1999-2013

0.5 1.0 1.8 1.3 0.3 2.9 6.3 4.4 3.8 2.1

1 2 3 4 5 6 7

15-24 years 25-34 years 35-44 years 45-54 years 55-64 years

Rate per 100,000

1999 2013

Source: CDC/NCHS WONDER-National Vital Statistics System, Mortality File

Rates per 100,000 of Drug Poisoning Deaths Involving Other Opiates in the US: 1999-2013

0.5 1.3 2.3 2.0 0.7 0.3 2.7 7.6 8.7 10.7 7.5 1.4 2 4 6 8 10 12 15-24 years 25-34 years 35-44 years 45-54 years 55-64 years 65-74 years Rate per100,000 1999 2013

Source: CDC/NCHS WONDER-National Vital Statistics System, Mortality File,

Jane Maxwell, UT Addiction Research Institute, 512 232-0610

Estimated Number of Patients Receiving MAT: 2002-2013

200,000 400,000 600,000 800,000 1,000,000 1,200,000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Buprenorphine (Duo) Buprenorphine (Mono) Methadone NSSATS Naltrexone (Oral) (Opiate Dep)

Source: IMS Total Patient Tracker, Sep 2014. Buprenorphine data exclude forms indicated for pain. Oral naltrexone factored for opioid dependence use only (40% factor provided by Alkermes). Methadone patients, N-SSATS

Opioid and Heroin Patients Receiving Methadone or Prescriptions for Buprenorphine or Naltrexone vs. Abuse/Dependent or Past Month Users of Pain Relievers Nonmedically or Heroin: 2012

1,462,069 5,197,000

Opioid and Heroin Patients Receiving MAT* Past Month Use of Pain Relievers or Heroin NSDUH 2012

* Number of individuals receiving buprenorphine or naltrexone from IMS plus number of patients receiving methadone from NSSATS. Source: IMS Total Patient Tracker, Sept 2014 and SAMHSA NSSATS. Buprenorphine data exclude forms indicated for pain. Oral naltrexone factored for opioid dependence use. Methadone patients from SAMHSA, N-SSATS 2012.

Additional Needs

• Consistent Prescription Monitoring Programs with

real-time information across state lines.

• Current data to determine changes in trends.
• Use available data such as ARCOS and NFLIS data

to pinpoint areas where prescribing practice rates do not show balance between pain relief and patient safety.

• Limits on size of patient loads?
• Increase the number of addiction specialists to treat

patients on these new meds.

• Cost of buprenorphine & naltrexone and

reimbursement?

Jane Maxwell, UT Addiction Research Institute, 512 232-0610

Questions for the Audience

• Are today’s methadone programs easily accessible

and attractive to new young suburban patients?

• Do we need new treatment modalities such as

detoxification to attract aging Baby Boomers addicted to pain pill and benzos?

• Parallel prescribing of naloxone and pain pills for

selected patients are non-compliant, on high daily doses, have been switched to another opioid, have COPD, sleep apnea, depression, or unable cognitively to manage their meds. Education for family on signs of overdose and use of naloxone.

• Lack of knowledge about new MATS and targets for

use + stigma of and by users

Jane C. Maxwell, Ph.D. Senior Research Scientist Addiction Research Institute Center for Social Work Research The University of Texas at Austin 1717 West 6th, Suite 335 Austin, Texas 78703 512 232-0610

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