The intranasal heroin epidemic among Latino adolescents in Texas: they're calling it "cheese."

1
The intranasal heroin epidemic among Latino
adolescents in Texas they're calling it
"cheese."
?
Carlos F. Tirado1 Jane C. Maxwell2 Bryon H.
Adinoff1 1University of Texas Southwestern
Medical Center, Division on Addictions and NIDA
Clinical Trials Network, Texas Node 2University
of Texas at Austin, Addiction Research Institute

• Background
• Since 2005, Dallas County has experienced a sharp
  rise in the availability and use of intranasal
  heroin, commonly known on the street as cheese.

Concerning Trends

• Demographic Characteristics
• (18 and under)
• (Dallas County admissions data 2005-08)
• Avg age at admission 16.4 y/o
• MaleFemale ratio 11.2
• Percent Hispanic 91
• Percent involved with juvenile justice 49
• Percent with no prior treatment 99
• Percent living with parent 96.8
• Percent with substance abusing parent in home
  22
• Average grade level 8.3
• Percent IV use at time of admission 5.2
• Percent with any IV use (lifetime) 9.1
• For ages 15-19, Marijuana (32) and Cocaine (16)
  were most common second drugs of choice
• Percent with co-morbid psychiatric problems 24
• Clinical/Behavioral Charateristics (n25)
• Majority (gt90) of teens bought or were given
  first doses as powder
• Majority (gt95) of regular users were directly
  purchasing black tar heroin and mixing it with
  OTC sleep aids for personal use

Evidence-Based Intervention in Community
Treatment Center (CTP) Findings from RCTs
(Marsch, LA, et al.1, and Woody, G, et al.2)
established feasibility and effectiveness of
extended treatment with buprenorphine in an
adolescent/young adult population. Rationale
derived from RCTs - An extended course of
buprenorphine beyond a traditional detox time
frame (4-12 weeks) may impart some level of
lasting benefit - Extended, but time limited,
treatments may be an alternative to long term
maintenance treatments in adolescents

• Heroin Deaths by Age in Dallas County
• Increase in percentage of deaths in persons
  less than 30 y/o

30
18
30
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Cheese is the combination of black tar heroin
with OTC sleep medications containing
diphenhydramine or doxylamine succinate. Average
purity ranges from 2-5 heroin. Community
mobilized following highly publicized overdose
deaths and presentation of children as young as 9
years of age in acute heroin withdrawal Dallas
County health commissioner convened a city-wide
task force to organize education, prevention and
treatment strategy
26
26
23
13
12
7
6
8

• Buprenorphine Pilot Program for
• Adolescent Intranasal Heroin Users
• Result of collaboration between managed Medicaid
  provider and CTP to implement evidence based
  medication assisted treatment (MAT) in a
  naturalistic setting.
• A meet in the middle approach intended to
  balance cost-effectiveness with quality care
• Primary Aims
• To prevent or delay relapse to IN heroin
• To engage families in treatment process

97 of all heroin related deaths were found to
have co-occurring substances at autopsy 53
Cocaine 36 Alcohol 23 Cannabis 20
Benzodiazepine
Deaths recorded up to 07/01/2008

• Disproportionate Impact on Hispanics
• Increase in percentage of Hispanics entering
  treatment statewide for heroin dependence between
  1989-2007 (TEDS data)

Geographically Confined to Dallas
County Distribution of intranasal heroin
admissions by ZIP code
Program Schematic
Program Details - Patients stabilized for
extended treatment within residential program -
During brief residential stay, patient and
family are introduced to MAT and prepared for
IOP - 90 day supply of Bup/Nal provided by
insurer at no cost - Medication is dispensed in
weekly intervals, supply kept by CTP medical
staff - Family group visit is yoked to weekly
medication visit

• Dallas YRBS Survey 2005 and 2007
• Relative Increase in percentage of school age
  Hispanics using intranasal heroin in Dallas

Transition to school, job, normative behavior
Yearly Distribution 2005-2007 Yearly Distribution
of intranasal heroin admissions by ZIP
2005
2006
2007
Preliminary results for 8 females entering pilot
program since 10/2007

• TEDS data 1989 to 2007
• Decline in average age of admission for heroin
  inhalers statewide.

Figure Legend
34
Bupe clean UDS

• References
• Marsch, LA, et al., Comparison of pharmacological
  treatments for opioid-dependent adolescents a
  randomized control trial. Arch Gen Psychiatry,
  Oct. 62(10) 1157-64, 2005
• Woody, G., Findings from a NIDA-CTN clinical
  trial of Bup/Nal-facilitated rehabilitation for
  opioid-dependent adolescents/youth adults, CPDD
  annual meeting, June 19th, 2007
• - Coleman, JJ, Special Report Cheese-Heroin in
  Dallas, TX, Dallas Heroin Task
• Force, Dec 12, 2007
• - Maxwell, JC, Cheese Heroin The Picture Gets
  Clearer and the Problem
• More Worrisome, SAMHSA, Dec 09, 2007
• Supported by Grant U10DA020024, Protocol CTN
  0036, Clinical Trials Network (CTN) - National
  Institutes of Drug Abuse, NIH Office of Health
  Disparities Research

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Bupe, dirty UDS but engaged in treatment

• Highest concentration of cases originating from
  the 75220 and 75217 ZIP codes.
• Cases in 75220 ZIP originating from specific high
  school and middle school.

AMA Discharge, Relapse