Trends in Pharmaceutical Opioid Abuse in Ohio

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Trends in Pharmaceutical Opioid Abuse in Ohio

• Robert G. Carlson, Ph.D. Raminta Daniulaityte,
  Ph.D. Tamara Hansen Reese, M.P.H Lawrence
  Hammar, Ph.D. Russel Falck, M.A.
• Center for Interventions, Treatment, and
  Addictions Research
• Wright State University Boonshoft School of
  Medicine 3640 Colonel Glenn Hwy., Dayton, OH
  45435
• Phone [phone] Fax [phone]
  www.med.wright.edu/citar/

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Ohio Substance Abuse Monitoring Network

• Funded by the Ohio Department of Alcohol and Drug
  Addiction Services (ODADAS)
• Wright State and U Akron/Kent contracted (1999
  June 30, 2009)
• Regional epidemiologists in 8 areas across the
  state conduct qualitative research to provide
  epidemiological descriptions of substance abuse
  trends and emerging problems every six months.

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Methods

• Qualitative individual interviews and focus
  groups with
• Active and recovering users
• Treatment providers
• Probation officers
• Law enforcement
• Crime lab professionals
• Statistical data are used to triangulate and
  enhance qualitative findings
• Local school surveys
• Crime lab surveys
• Coroners reports
• Statistics on substance abuse treatment
  admissions

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OSAM Products

• General Epidemiological Reports
• 2 per year
• OSAM-O-GRAMs
• 12 per year
• Brief reports summarizing key findings and
  emerging trends distributed by e-mail or fax
• About 800 individuals receive Osam-o-grams
• Targeted Response Initiatives
• 1 per year
• January 2002 Young/new heroin users
• January 2003 Heroin use in Marietta
• June 2003 Pharmaceutical opioid abuse
• January 2006 Treatment experiences among young
  heroin users
• June 2008 Drug abuse trends in rural areas
• All reports are available on the ODADAS web site

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Pharmaceutical opioids

• Pharmaceutical opioids belong to a class of drugs
  that consists of naturally-occurring,
  semi-synthetic, and synthetic agents that have
  opium or morphine-like effects.
• The pharmaceutical opioids commonly used in the
  US include
• codeine, hydrocodone, oxycodone, propoxyphene,
  meperidine, hydromorphone, morphine, methadone,
  fentanyl, tramadol, buprenorphine, oxymorphone
• Opioids produce their effects by binding with one
  or more opioid receptors (i.e., sites located on
  cell membranes) present in the bodys endogenous
  opioid system
• Psychophysiological effects of opioid use can
  include analgesia, drowsiness, changes in mood,
  mental cloudiness, and euphoria.
• Physical effects can include respiratory
  depression, cough suppression, pupillary
  constriction, and a host of gastrointestinal
  actions
•  

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Opiates and Opioids

• Opiates natural (morphine) or semi-synthetic
  agents (heroin, buprenorphine, hydrocodone,
  oxycodone, oxymorphone)
• Opioids refers to any drug that binds to opioid
  receptors in CNS. Includes synthetic drugs
  methadone, fentanyl, tramadol
• Opioids is a broader concept than opiates.

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Hydrocodone

• Consistent reports about high availability of
  Vicodin, easy access across the state.
• Oral use, reports about crushing and snorting,
  especially among young party-goers
• In 2007-2008, treatment providers in Dayton noted
  increasing admissions related to hydrocodone
  abuse.
• As one treatment provider noted, Our primary one
  has been and still is Vicodin. Vicodin is huge.
• Another treatment counselor noted that theres
  been a trend away from OxyContin.

Vicodins are hot on the market, they are off the
chart (HIV prevention specialists, Dayton )
Its probably your easiest pill to get out
there. (User, Dayton)
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Oxycodone

• OxyContin (oxycodone, extended-release)
• In 1999-2000, first reports about growing problem
  of OxyContin abuse in Ohio. 2004, first reports
  about generic OxyContin abuse
• Over time, availability has generally been
  moderate to high some declines and fluctuation.
• Demand remained very high over time.
• Taken orally, crushed and snorted reports about
  injection use
• Percocet (oxycodone and acetaminophen)
• Easy availability in most areas of the state
• Taken orally, crushed and snorted

After I snorted it OxyContin that day, shoo! I
was in love. It was almost like the first time I
ever shot cocaine. I was in love. So, me and
everybody that lived in the house at that time,
we all got addicted to Oxys. (White woman, 49,
Dayton )

• An opioid-user from Columbus commented, I
  would get pillsmaybe someone else got in a
  motorcycle accident or a car crash and theyre
  prescribed Percocet and you can buy em for 3,
  4 a pill, and you chop it down and snort it.

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Methadone and other pharm opioids

• In 2004, some increases in availability of
  methadone tablets/wafers. Since then, most
  regions generally reported moderate availability
  (some fluctuations across time and regions).
• High demand among users who try to self-medicate
  heroin/other opioid addictions. Reports about
  liquid methadone abuse very rare.
• In 2008, methadone wafers no longer prescribed
  for pain management street availability of
  wafers drops, tablets remain moderately
  available.
• Dilaudid (hydromorphone), morphine tablets,
  fentanyl patches, tramadol, codeine (including
  cough syrup) availability and abuse vary by
  region and over time.

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Buprenorphine

• In 2005, initial user reports about Suboxone
  (buprenorphine and naloxone) diversion and
  illicit use since then, its illicit use has
  increased across the state.
• Illicit use of Suboxone has generally been more
  common than that of Subutex.

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Buprenorphine

• Prices vary across the state, although some
  declines were noted.
• In some areas, Suboxone prices declined from 20
  per 8-mg tablet in 2006 to 5-10 in 2008.
• Users typically buy Suboxone on the street to
  self-medicate their addiction to heroin or
  pharmaceutical opioids.
• Reports of using Suboxone to get high have
  been low across Ohio.

• I've taken that Suboxone a handful of
  timesto get well I had a connection for a
  little bit for it It's very powerful you can
  easily break it up, and you can take just a
  speck, but it's miraculous. (42-year-old white
  female heroin user, Toledo )
• I have got a couple phone calls saying I
  want to start Suboxone here because I've been
  buying it on the street, and it's working.
  (Substance abuse treatment provider, Toledo)

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Opana (oxymorphone)

• In 2008, initial reports about Opana abuse in the
  Cincinnati, Dayton, and Athens areas.
• Opana ER sells for
• 20 for a 20-mg tablet
• 40 for a 40-mg tablet.
• Users in Athens and Cincinnati indicated that the
  Opana high was comparable to or even better
  than that of OxyContin.

I actually heard of a new thing .... And I guess
its pretty popular around here. Its called an
Opana.(White woman, Athens area)
And I guess you can get really blown out of it,
for less than a tablet of OxyContin. (White
woman, Athens area) The oxymorphone is the best
. . . even better than oxycodone. I can do a
whole Oxy 80 80-milligram strength tablet of
OxyContin and nothing happens, but if I take one
of them pills Opana ER I can get a buzz
thats how I get the energy to do things around
the house. (White woman, Cincinnati)
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Orange Stop-Signs

• Suboxone Opana

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Pharmaceutical opioid availability trends
according to the Rural TRI

• The OSAM Rural Targeted Response Initiative (TRI)
  found remarkably high levels of pharmaceutical
  opioid abuse in the rural counties designated by
  the study
• For example, in Williams County, pharmaceutical
  opioids were ranked by users as the number one
  drug in the county.
• A Pickaway County user commented, Pills are
  really a big thing, a really big thing here in
  Circleville. Its bad. I think people would trade
  anything for pills.

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Availability of Diverted Pharmaceutical Opioids
According to OSAM Network General Trend Report
and Rural Targeted Response Initiative, 2008
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Pharmaceutical Opioids Sources

• Pill dealers - some people sell their own
  prescriptions to supplement limited incomes.
  Extended networks via cell phone.
• Taken from home medicine cabinets (especially
  adolescent users)
• Over-prescribing (especially among older
  adults)
• Doctor shopping - ER and dentists were
  frequently mentioned

Id sneak in my moms room, and just take a
couple here and there. And thered be
80-milligram OxyContins, thered be uh, thered
be uh, Klonopin 2-milligrams, there would be um,
Lortab And I would sneak in, and then I would go
to school and sell em. (White man, early 20s,
Dayton)
I could walk into ER and say I got pain in my
back and get Vicodins . (User)
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Pharmaceutical Opioids Street Prices

• Prices have remained relatively stable over the
  years.
• Some increases in OxyContin prices.
• Most pharmaceutical opioids sell for about
  0.50-1 per milligram of opioid content.

Street prices of pharmaceutical opioids in the
Dayton area, January 2009
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Pharmaceutical Opioid Users

• High levels of abuse among diverse user groups
• Adolescents and young adults
• More common among whites than African Americans
• Middle-aged and older users with chronic health
  problems
• Primary users of other drugs (heroin, crack)
• Pain pill abuse regardless of socioeconomic
  background.

Oh, the pills, that's huge among high school
students! They don't even know what they're
taking and don't seem to be concerned about it.
(School counselor, Dayton )
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Pharmaceutical Opioid Use Patterns, Perceptions,
and Risks

• Reason for use to party, to get high and to
  self-medicate emotional and physical pain.
• Most pharmaceutical opioids, except OxyContin,
  are typically viewed as low-risk drugs by users.
• Most are used orally
• snorting is common as well (OxyContin)
• reports about injection use of OxyContin
• Frequently used with a number of other drugs,
  including marijuana, alcohol, benzodiazepines,
  other pharmaceuticals.

The pain in your life, pain in your heart and
soul it opiates takes it all away. (White
woman, 24 started using pain pills at 14)

• Yeah, I think it's a perception that since it's a
  pharmaceutical, it's not dangerous. You know,
  since it's prescribed by doctors, it's safer
  (Counselor)

If I was going to work or something, I would just
take the Lortabs and the Oxys. And then if I just
wanted to sit at home, I would mix a few Xanax
bars or Xanies with a couple Somas and about
three or four Vicodins, and Id be drinkin a
beer, smokin pot (White man, early 20s)
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Accidental Overdose Deaths in Montgomery County,
2008 (Montgomery County Coroners Office)

• Total no of accidental overdose cases in 2008
  132.
• More than 80 (n106) tested positive for
  pharmaceutical opioids.
• In 2007, there were 96 cases that tested positive
  for pharmaceutical opioids.

Note One case could have tested positive for
more than one pharmaceutical opioid.
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Pharmaceutical Opioid Abuse A Pathway to Heroin
Addiction

• In 2001, OSAM Network was among the first in the
  state to identify that pharmaceutical opioid
  abuse (especially OxyContin) has become a
  pathway to heroin abuse in the Dayton area.
• Since 2001, consistent, statewide reports
  indicating that pharmaceutical opioid abuse is an
  important contributing factor to an increasing
  trend of heroin addiction.
• According to TRI on young heroin users (2006)
• 58 people were interviewed across the state
  almost 65 believed they were addicted to
  pharmaceutical opioids (mostly OxyContin) before
  they used heroin for the first time.

I think if all my friends had never tried
OxyContins, it would have never led to the
heroin, never. Everybody that I know who uses
heroin started out with OxyContins. (White
woman, 18, Dayton, 2001) About 50 of our
heroin addicted clients shifted from OxyContin
or other pills to heroin. (Treatment provider,
Dayton, 2008)
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Explaining the Transition from Pharmaceutical
Opioids to Heroin Abuse
I knew it heroin was dangerous. I knew it
destroyed lives. I just didnt think it would be
mine. I just figured if I was doin the Oxys, I
might as well do the heroin, it was same thing. I
figured Im already this far into it, its the
same thing, might as well use it. (White woman,
22, Dayton, 2006)

• Rapidly increasing tolerance to pharmaceutical
  opioids
• Decreasing availability and high street prices of
  pharmaceutical opioids
• High availability and comparatively low prices of
  heroin
• A commonly shared belief that heroin is the same
  thing as OxyContin, which diminishes stigma and
  initial fears associated with heroin use.

I was sick one time and couldnt find any pills
OxyContin I was really, really sick. And I
couldnt work, and I couldnt do much, and a
friend a mine that was already usin heroin
turned me onto the heroin. He said that it would
take the dope sick away. And from there on, you
know, its cheaper, its quicker. (White woman,
29, Dayton, 2006)
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Trends in Heroin Prices

• --Huge increases in heroin availability and use
  across
• the state.
• --Declining prices.

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Increases in Treatment Admissions

• Since 2007, treatment facilities in Montgomery
  County have reported increases in white,
  opiate-addicted clients seeking treatment.

Were overpopulated, thats what it is. We
admitted 22 clients today, and were admitting
anywhere from 10 to 15 people a week and have
been since February . . . on an average month,
were admitting 65 -Treatment
provider, Montgomery County (2009)
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Increases in Hepatitis C
Younger, not only are they IV drug users with
heroin, but they also have Hepatitis C at a very
young age. Theres a lot of sharing going on
cause they dont know what theyre doing. The
person that theyre using the syringe or cooker
has Hepatitis C, they dont know so thats how
theyre getting it. -HIV Outreach
Worker, Montgomery County (2009)
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Opioid Use Trajectories and HIV Risk among Young
Adults in Ohio

• NIH/NIDA Grant No. 1 R01 DA 023577
• Mixed-methods approach to describing
  pharmaceutical opioid use trajectories over 36
  months.
• Recruit about 400 18-23 year-old non-dependent
  users.
• Identify characteristics associated with
  transition to dependence, thereby informing
  prevention.
• Key informant and focus group interviews to
  identify initial sampling seeds.
• Preliminary Insights.

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Participant Characteristics

• 36 participants interviewed in focus groups or
  individually
• average age at first (illicit) use for males was
  16.68 years (13-21)
• average age at first (illicit) use for females
  was 18.40 years (15-28)
• 23 white, 8 African-American, 4 Asian
  participants, 1 biracial
• average frequency of use of pain pills over past
  90 days, 40 days.
• Medical/Physical Trauma

I was, like, 15 when I broke my ankle, and they
gave me a prescription of Percs . . . and I just
havent really ever quit since. (white male)
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Sources of pharmaceutical opioids Streets
People dont pretty much sell pain pills on the
corner, like, they do crack and cocaine and
stuff, but theyll sell it, out of their homes,
at work, at school, stuff like that. (28-year-old
African American woman) I was at the bar and I
had a couple of them in my pocket and somebody
said Im lookin for, you know, Man, I wish I
had a Percocet, or something, and I said, hey,
I got two. Its another drink for me. (White
man) Client Well, I woke up this morning and
ate three Vike 7.5s, and they wasnt hard to
get, all I had to do is walk in the
alley. Interviewer What do you mean, theres
somebody standing out in the alley? Client Naw,
at a house. (White man)

• Extended networks of friends and acquaintances
• Pill houses
• Bars and clubs

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Sources Doctor shopping

• Emergency Rooms (ER) are easy targets
• Those with prior medical problems find it easy to
  manipulate the system
• Getting pills for personal use and for selling
  (as a way to make money)

Most of the time I used to go to a Hospital in
Southwest Ohio. Thats where I would get
everything prescribed to me. You walk in there
and youre walkin out with whatever you want,
like, Oh, no, that dont work so I need this
'cause this works better. So, okay here you
go. (White man)
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Sources Doctor shopping

Theyll get the phone book, find doctors name,
say, the doctors, John Smith. So theyll call
the after-hours line, and say, um, Can I get the
doctor on call for John Smith? The doctor will
call 'em back, and theyll say, um, Im one of
Dr. Smiths patients, my name is blah, blah,
blah, I got bronchitis, you know, I need my
medication, Im goin out of town, or death in
my family, whatever excuse they give 'em, and a
lot of times these doctors, just call up the
scrip, Well, Dr. Smith usually writes me, 240
ml, you know, take it twice a day. They know,
exactly how a doctor will write it(African
American man)
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Columbus drug scene Availability of
pharmaceutical opioids

• The streets extended networks via cell phone
  and texting have become a clandestine market for
  an incredibly wide range of diverted chemicals
  designed to make people feel better and/or
  improve performance.

The availability is so good because the people
want to get rid of 'em that bad thats why they,
we dont have to really search it finds us.
People text you, saying, Hey, you know, I got
this You want it, you want it? People are
pushing, tryin to push 'em away. I mean, thats
how available they are. (white female)
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Columbus drug scene Prices

I could get Roxicet for 4 a piece Percocet 5s,
4 a piece Perc 10s 6 a piece Perc immediate
release oxycodone 15s are, like, 10 a piece
and then Perc immediate release oxycodone 30s,
those go for 20. And the Oxys, those go for a
dollar a milligram, and Vicodin 5, 2 Vicodin
10, 4 and then, um, Valium 5s are a dollar
and then the Valium 10s go to 2 and the V
cuts go to 5. (Active user , Columbus)
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Conclusions

• Increases in pharmaceutical opioid and heroin
  abuse began in Ohio around 2000. Illicit use of
  pharm opioids shows no signs of decreasing.
• Synergy between illicit opioid (heroin) and
  licit, but diverted pharmaceutical opioids.
• pharmaceutical opioid abuse and dependence create
  a market for heroin
• Rural and urban areas equally impacted.
• Public Health Implications Opioid-related
  overdose deaths increasing Hepatitis C
  infections increasing HIV risk increasing.
• Local drug abuse treatment programs struggle to
  meet the increasing demand for opioid-specific
  treatment.
• Why? Easy access to pharmaceutical opioids,
  declining heroin prices. Pleasure-pain continuum.
  Humans seek to increase pleasure and reduce
  painnot just physical. Increasing disjunction
  between the peoples life goals and the means
  they have to achieve them.

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Thank You

• Please visit the Center for Interventions,
  Treatment, and Addictions website for more
  information on our research and intervention
  projects.
• http//www.med.wright.edu/citar/