SUBSTANCE ABUSE TRENDS

1
SUBSTANCE ABUSE TRENDS

• THE AVISA GROUP
• SEPTEMBER 2005

2
DATA AND INFORMATION ON PRESCRIPTION DRUGS AND
TRENDS IN SUBSTANCE ABUSE

• HEROIN
• OTHER NARCOTICS
• OXYCONTIN
• VICODIN
• METHADONE
• BUPRENORPHINE
• METHADONE IN CALIFORNIA

3
HEROIN

• Heroin is widely available in the United States.
  In 2004, the National Survey on Drug Use and
  Health (NSDUH) estimated that 398,000 Americans
  used heroin in the previous 12 months1.
  However, it is difficult to obtain an accurate
  measure of use because of the transient nature of
  much of the heroin using population. The Office
  of National Drug Control Policy estimates that
  there are between 750,000 and 1,000,0002.
• These varying estimates of use imply that
  evidence from trends or comparisons across
  geographic areas derived from the same sources
  will be useful information, but that precise
  estimates of the absolute prevalence must be used
  with caution.
• Use of heroin in the United States has varied
  over time. In general terms, use rates were high
  in the 1970s, fell to a lower level and remained
  at that level in the 1980s and early 1990s,
  rose in the second half of the 1990s, and appear
  to have declined some since 2000, although not to
  the use rates that were characteristic of the
  1980s.

4
HEROIN TRENDS IN ANNUAL PREVALENCE OF USE

• A data series from Monitoring the Future3
  provides the best available measures of the
  prevalence of heroin abuse over time in the
  United States. The results of their surveys,
  which started in 1976, are shown below. Note,
  that the surveys began with 18 year olds only,
  and then progressively added older age groups
  over time.

5
HEROIN USE AMONG ARRESTEES

• The percentage of arrestees who test positive for
  opiates, predominantly heroin, has remained
  steady since 20004.

6
HEROIN GEOGRAPHIC DIFFERENCES IN USE

• Opiate addiction is best understood within a
  REGIONAL framework. Substances and patterns of
  abuse have unique regional characteristics.
• Use of Heroin varies by geographic area of the
  United States. The Community Epidemiology Work
  Group reported in 2005 that In 2003 2004,
  heroin abuse indicators were stable or mixed in
  15 CEWG areas, but high in Midwest and Northeast
  areas. Heroin indicators decreased in five areas
  (Denver, Honolulu, San Diego, San Francisco, and
  Seattle) located in the western half of the
  nation, and increased only in Washington, DC5.
• The percentage of arrestees who test positive for
  opiates varies greatly by geography. The
  following are the percentages in 2003 for some
  regions of interest to CRC
• Indianapolis, IN 5.1
• Los Angeles, CA 2.0
• Portland, OR 15.0
• Sacramento, CA 6.9
• San Diego, CA 5.1
• The following Chart shows use rates among twelfth
  graders since 1976. The South and the West are
  generally lower in use rates than the Northeast
  and North Central regions.

7
INFORMATION FROM AVISA INFORMANTS ON REGIONAL
TRENDS IN HEROIN ABUSE

• There is no perceived decline in the incidence
  and prevalence of heroin abuse in the Northeast
  corridor. Demand remains high and may be slightly
  increasing, according to law enforcement contacts
  throughout the region.
• Highly pure (gt 50) China white heroin is
  widely available throughout the Northeast
  corridor. This type of heroin can be abused
  through snorting, smoking, or injection.
• Retail prices are stable but the cost per high
  is decreasing, because of the increasing purity
  of the drug available on the street in the
  Northeast.
• There is little perceived cross-over abuse of
  OxyContin by street heroin addicts in the
  Northeast. (OxyContin is not a problem for
  ustheres too much good quality heroin on the
  streetJohn Galea, Director of the Street
  Studies Unit of the New York Office of Alcohol
  and Substance Abuse Services.
• There is little to no heroin abuse evident in
  Appalachia. The prevailing explanation for this
  fact is that retail heroin distribution is
  largely controlled by urban, African-American
  criminal gangs with few to non-existent contacts
  in the Appalachian region.
• Opiate abuse appears to be stable or even
  slightly increasing in California over the last
  few years. Demand for street heroin appears to be
  stable in California and slightly decreased in
  the Pacific Northwest. Demand for prescription
  opiates, either through legal MD prescriptions
  or diversion, is increasing significantly
  throughout the region. There is no decline in
  opiate abuse detectable from other non-treatment
  data bases (mortality and morbidity, law
  enforcement, etc.)
• Black tar heroin from Mexico is the predominant
  form of heroin available throughout the West
  region. It is widely available, with wholesale
  prices down over the past few years and purity
  increasing. However, even with recent increases
  in purity, most heroin available in the region is
  only 20-25 pure (compared to gt 50 in the East).

8
REGIONAL TRENDS IN HEROIN USE
9
OTHER NARCOTICS

• Use of narcotics other than heroin has been
  increasing in the United States since the early
  1990s.
• The Community Epidemiology Work Group, reported
  in January 2005 that narcotic analgesic drug
  abuse indicators increased in almost all CEWG
  areas in 2003 2004
• The long term trend, from Monitoring the Future,
  shows use declining throughout the 1980s but
  beginning a rapid increase in the mid 1990s.
  Although the rate of use among 18 year olds
  appears to have leveled off in 2003 and 2004, a
  leading indicator of trends in use in the general
  population, it is still increasing among older
  age groups.
• Use rates in the South and the West are generally
  lower than those in the Northeast and North
  Central regions.

10
OTHER NARCOTICS USE TRENDS BY AGE CATEGORY
11
OTHER NARCOTICS INFORMATION FROM AVISA
INFORMANTS

• Prescription opiates, obtained either legally
  through an MDs prescription or illegally through
  street diversion of pharmaceutical drugs, have
  been and remain the opiate of choice in the
  Appalachian region. OxyContin has in the past
  been a major drug of abuse but all other
  prescription opiates (Vicodin, codeine, etc.)
  are also abused as available.
• With the recent increases in opiate prescription
  abuse throughout the West region, cross-over
  abuse between classes of opiates is beginning to
  become more widespread. As opposed to the East,
  where heroin addicts remain largely confined to
  heroin use, and the Appalachian region, where
  opiate addicts abuse almost entirely prescription
  drugs (OxyContin and increasingly methadone), in
  California opiate addicts appear more likely to
  abuse one or more class of opiates at different
  times.

12
OTHER NARCOTICS USE TRENDS BY GEOGRAPHY
13
OXYCONTIN

• OxyContin was introduced in 1995 by Purdue
  Pharma
• OxyContin contains the drug oxycodone in a
  timed-released tablet
• A generic version of OxyContin produced by Endo
  Pharmaceuticals was launched 06/08/2005
• Prescription data from Drug Topics shows the
  following trend of the number of OxyContin
  prescriptions from 2000 - 2004

14
OXYCONTIN

• OxyContin is a subject of the DEAs National
  Action Plan to reduce diversion and abuse of
  prescription drugs
• DEA reports that DEAs National Action Plan has
  been successful in addressing OxyContin
  diversion as evidenced by (1) a reduction in the
  rate of increase of OxyContin prescriptions
  being written and (2) a leveling-off of
  OxyContin sales since the Plans implementation
  in the Spring of 2001. Karen Tandy,
  Administrator, DEA 3/24/2004.
• One key strategy that the DEA urges States to
  take in order to reduce the diversion of
  prescription drugs is a Prescription Drug
  Monitoring Program. Research has shown that
  these programs can be effective when properly
  implemented. A portion of the costs of these
  programs is supported by the DEA and the Bureau
  of Justice Assistance. As of August 2005, such
  programs exist in 26 States, including the
  following States where CRC has a substantial
  number of methadone clinics California, Indiana,
  and West Virginia.
• The Prescription Drug Monitoring Program in West
  Virginia was re-enacted in 20026, after having
  been discontinued in 1998. The reenactment
  followed a steep increase in the distribution of
  oxycodone in the State following discontinuation
  in 1998 and was responsible for a leveling off of
  the amount of oxycodone distributed in the State
  in 2002 and thereafter.

15
OxyContin

• At a January 2005 meeting convened by the
  National Institute on Drug Abuse (NIDA), the
  Community Epidemiology Work Group identified the
  following trends
• Oxycodone abuse indicators were identified more
  often than indicators for other analgesics
• In Los Angeles, other opiates/synthetics
  continued to constitute a marginal proportion of
  all Los Angeles County treatment admissions
• Like other drugs of abuse, the illicit use of
  OxyContin varies considerably by region. The
  chart below, from Monitoring the Future shows a
  two year trend by region for use among twelfth
  graders, an indicator that has been shown to be
  predictive of future use. The data indicates use
  declining in the Northeast and North Central
  regions, increasing substantially in the South
  and leveling off in the West.
• Avisa informants report that OxyContin abuse
  continues in Appalachia but has decreased over
  the last two years. The perception is that this
  decrease is due to the efforts of law enforcement
  to curtail abusive prescribing practices among
  some of the regions doctors.

16
OxyContin
17
VICODIN

• Vicodin is a form of hydrocodone bitartrate and
  acetaminophen supplied in tablet form for oral
  administration, manufactured by Abbott
  Laboratories. Other trade names of this
  combination include Anexsia, Hycodan,
  Hycomine, Lorcet, Lortab, Tussionex, Tylox,
  and Vicoprofen.
• The combination of hydrocodone bitartrate and
  acetaminophen was the most frequently prescribed
  drug in the United States in 2004.
• From 2000 to 2004, the number of prescriptions
  increased at an average annual rate of 8.
• Like other drugs of abuse, the illicit use of
  Vicodin varies considerably by region. The data
  indicates that illicit use among twelfth graders,
  a leading indicator of trends in the general
  population, is declining in the North Central
  region, and leveling off in 2004 in the other
  regions.

18
METHADONE

• There are two distinct markets for methadone
  Narcotic Treatment Programs (Methadone Clinics)
  and retail distribution. The Drug Enforcement
  Administration permits the use of methadone to
  treat addiction to opiates to be performed ONLY
  by methadone clinics (with the small scale
  exception of certain office-based opioid
  treatment program pilot projects). However,
  physicians are permitted to prescribe methadone
  for other purposes, including most importantly
  for the alleviation of pain. The amount of
  methadone supplied to retail pharmacies, which is
  the distribution channel associated with
  methadone prescriptions for the treatment of
  pain, has been increasing rapidly (Data from the
  DEA data is missing for calendar year 2000).
• Methadone supplied to pharmacies for use in
  treatment of pain is distributed in the form of
  tablets methadone supplied to NTPs is
  distributed in the form of powder that is mixed
  as a liquid for administration to clients.

19
RETAIL SHIPMENTS OF METHADONE
20
METHADONE

• Anecdotal reports from the West region of the
  United States suggest that prescription
  methadone, in the form of tablets, is
  sufficiently inexpensive on the street that some
  potential clients of methadone clinics find the
  drug is cheaper to purchase on the street than it
  is to obtain from a methadone clinic.
• Data from the DEA show that the quantity of
  methadone supplied through the retail
  distribution system is approaching the quantity
  supplied to methadone clinics. By the end of
  2004, in the South and West, retail distribution
  exceeded and in the Northeast equaled the
  quantity supplied to methadone clinics. The
  Northeast is the only region where the quantity
  of methadone supplied to the retail channel is
  below the quantity supplied to NTPs.
• The flattening of the trend line of methadone
  shipments to NTPs beginning in the last quarter
  of 2003 on a national basis may be due, in part,
  to the ongoing increase in the distribution of
  methadone through the retail channel. The
  Northeast region of the US is the only region
  where retail shipments of methadone are
  significantly below shipments of methadone to
  NTPs, and is also the only region where shipments
  of methadone to NTPs and is also the region that
  was experiencing the most rapid growth in
  shipments to NTPs during the second half of 2004.

21
SHIPMENTS OF METHADONE TO NTPS AND RETAIL SETTINGS
22
METHADONE INFORMATION FROM AVISA INFORMANTS

• There is some diversion of methadone from
  treatment programs to street abuse in the
  Northeast reported by Avisa informants, with
  methadone commanding a price of 1 per mg in NYC.
• In Appalachia, an increase in the abuse of
  methadone obtained through non-OTP channels has
  been noted. This non-OTP methadone is obtained
  either from an MDs prescription or through
  street diversion from pharmacies and doctors
  offices. (Every time we do a search warrant now,
  we seem to find methadone.George Sungy, DEA
  Intelligence Analyst, Appalachia High Intensity
  Drug Trafficking Area)

23
BUPRENORPHINE

• Buprenorphine was approved by the FDA for use in
  treatment of opioid abuse and dependence in
  October, 2002. Under the Drug Abuse and
  Treatment Act (DATA), physicians may request a
  waiver that permits them to prescribe
  buprenorphine from their offices it may also be
  used by NTPs.
• Shipments of buprenorphine got off to a slow
  start in 2003, but increased in 2004

24
BUPRENORPHINE

• Buprenorphine is much more expensive than
  methadone, with a retail price that is an average
  of 9 - 11 per day for the medication. The
  market for buprenorphine treatment is different
  from the market for methadone treatment of opiate
  abuse and dependence. Patients treated with
  buprenorphine are more likely to be employed,
  have higher income and educational levels, and
  are more likely to be white than are methadone
  patients.
• To date, the introduction of buprenorphine does
  not appear to have had an impact on the market
  for methadone treatment, in large part because of
  the difference in patient populations for the two
  treatment options.

25
METHADONE IN CALIFORNIA AND THE WEST COAST

• California often leads the rest of the country in
  many social trends.
• In the West, shipments of methadone through the
  retail channel exceeded shipments to NTPs in the
  second quarter of 2004.

26
METHADONE

• According to data from SAMHSA, the annual number
  of admissions for methadone treatment in
  California have been declining since 1994.

27
METHADONE

• Our research and inquiry into the phenomenon of
  declining admissions for methadone treatment in
  California has revealed the following factors
  that have contributed to this decline in
  admissions to methadone treatment
• A portion of the increasing supply of methadone
  in the retail market is becoming available on the
  street at prices that are below those charged by
  methadone clinics for a treatment visit. In
  essence, patients can get the drug that
  constitutes the major component of their
  treatment more cheaply and with fewer
  requirements on the street than they can from a
  clinic.
• Proposition 36 in California the Substance
  Abuse and Crime Prevention Act injected 100
  million of new funding into the substance abuse
  treatment system, beginning in 2001. Some
  clients who prior to the implementation of SACPA
  were not eligible for public funding for their
  treatment and had to pay out of their own pocket
  gained access to a new source of payment for
  substance abuse treatment. However, the
  treatment under SACPA is managed by the courts in
  California, who have historically been hostile to
  methadone treatment. Therefore, SACPA may have
  diverted some patients away from methadone
  treatment beginning in 2001.
• Some contacts emphasized the growing importance
  of a self-treatment use of opiates, especially
  methadone obtained through MD prescription
  outside traditional methadone treatment programs,
  and even diverted buprenorphine.

28
SOURCES OF STATISTICS

• 1 Substance Abuse and Mental Health Services
  Administration. (2005). Overview of Findings from
  the 2004 National Survey on Drug Use and Health
  (Office of Applied Studies, NSDUH Series H-27,
  DHHS Publication Number SMA 05-4061). Rockville,
  MD
• 2 Executive Office of the President, Office of
  National Drug Control Policy, Drug Policy
  Information Clearinghouse, Fact Sheet Heroin
  June 2003 NCJ 197335
• 3 Johnston, L.D., OMalley, P.M., Bachman,
  J.G., Schulenberg, J.E. (2005). Monitoring the
  Future national results on adolescent drug use
  Overview of Key Findings, 2004 (NIH Publication
  No. 05-5726). Bethesda, MD National Institute on
  Drug Abuse
• 4 US Department of Health and Human Services,
  National Institutes of Health, National Institute
  of Drug Abuse, Epidemiologic Trends in Drug
  Abuse Proceedings of the Community Epidemiology
  Work Group, January 2005
• 5 National Opinion Research Center, Arrestee
  Drug Abuse Monitoring Program, Drug and Alcohol
  Use and Related Matters Among Arrestees 2003.
• 6 GAO Prescription Drugs state Monitoring
  Programs Provide Useful tool to reduce Diversion
  May 2002 GAO-02-634

29
INFORMANTS ROF OVERVIEW AND CONTRACTING

• Gary Henschen M.D.
• Southern Regional Medical Director, Magellan
  Health Services
• Tom Hanline M.D.
• South Central Regional Medical Director, Magellan
  Health Services
• Bo Ciaverelli, M.D.
• Mid-Eastern Regional Medical Director, Magellan
  Health Services
• Greg Miller, M.D.
• Western Region Medical Director, Magellan Health
  Services
• Michael Glasser, M.D
• Senior Medical Director, Western Region, Managed
  Health Network
• Rowland Pearsall, M.D
• Medical Director, Eastern Region, Managed Health
  Network
• Don Fowls, M.D.
• Former CEO, Schaller Anderson Behavioral Health
  Care
• Former Senior Vice President, Value/Options
  Behavioral Care
• Craig Coenson, M.D.
• Senior Medical Director, CIGNA Behavioral Health
• Karin Wilson
• Director of Contact Negotiations, Managed Health
  Network

30
INFORMANTS REGIONAL TRENDS

• John Galea
• Chief of Street Research Unit, New York Office of
  Alcohol and Substance Abuse Services
• New York Community Epidemiology Work Group
• Thomas Carr
• Director, Washington-Baltimore High Intensity
  Drug Traffic Area
• Michael Lancaster. M.D.
• Chief of Clinical Policy, Division of Mental
  Health, State of North Carolina
• George Sungy
• Intelligence Analyst, Drug Enforcement Agency,
  Appalachia High Intensity Drug Traffic Area
• Erin Artigiani
• Deputy Director of Policy, Center for Substance
  Abuse Research, University of Maryland
• Baltimore/Washington Community Epidemiology Work
  Group
• Beth Rutkowski
• Epidemiologist, UCLA Research Center for
  Integrated Substance Abuse Programs
• Los Angeles Community Epidemiology Work Group
• Rudy Lovia
• Intelligence Analyst, Los Angeles Clearinghouse
• Caleb Banta-Greene
• Seattle Community Epidemiology Work Group