HIVAIDS and Substance Abuse:Connecting the Dots

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HIV/AIDS and Substance Abuse Connecting the Dots

• Jane C. Maxwell, Ph.D.
• Center for Excellence in Drug Epidemiology
• Gulf Coast Addiction Technology Transfer Center
• www.gcattc.net

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Data Sources

• Overdose death certificates Medical Examiner
  Reports (Texas Dept. of State Health Services)
• Poison Control Center cases (DSHS)
• Treatment admission records (TEDS-SAMHSA, DSHS)
• Price, purity, supply, trafficking data (DEA,
  NFLIS)
• Surveys (NSDUH-SAMHSA, MTF,YRBS, DSHS)
• Community Epidemiology Work Group (NIDA)
• Forensic laboratory tests (NFLIS, Police ME
  Labs)
• AIDS cases (Health Department, DSHS)

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• DEATH BY POWERPOINT
• I hope not!
• 1. Online data sources you can easily access when
  writing proposals.
• 2. Changes in the drug and alcohol scene over
  time and what may be coming in terms of HIV/AIDS
  risks.
• 3. Different ways to display the data to help
  people understand the problem.

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Community Epidemiology Workgroup Correspondents
Seattle
Maine
Minneapolis
Boston
Detroit
New York
Newark
Chicago
CVG
Philadelphia
San Francisco
Denver
D.C/Baltimore.
St. Louis
Los Angeles

Phoenix
Atlanta
New Mexico
San Diego
Honolulu
Austin
Miami
Map by JC Maxwell
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Drug Use Patterns Vary over Time and Space
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Percentage of Drug Items Analyzed by Tox Labs
Identified by Region, NFLIS 2007
Source NFLIS
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Percentage of Drug Items Identified by
Toxicological Labs as Heroin by State, 2006
25
Percentage of Drug Items Analyzed by Tox Labs
Identified as Cocaine, by State, 2006
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Percentage of Drug Items Analyzed by Tox Labs
Identified as Methamphetamine, by State, 2006
27
 Past Year Injection Drug Use among Persons Aged
12 or Older, by Region Percentages, NSDUH
2002-2005
Source SAMHSA
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2008 CEWG Reports South

• Georgia Females comprise 24 of AIDS cases, 76
  of new ADIS cases are Black.
• Florida 40 MSM, 17 IDU, 4 MSM/IDU
• Texas Majority of cases are non-White in 2007,
  54 MSM, 26 heterosexual, 14 IDU, 6 MSM/IDU.
• Baltimore 57 of AIDS cases in 2006 were IDU.

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2008 CEWG Reports West

• Seattle 2005-2007 cases 62 MSM, 8 MSM/IDU, 7
  heterosexual, 6 IDU.
• Colorado 2007 cases 61 MSM, 27 Other, 7 IDU,
  5 MSM/IDU. IDU decreasing.
• San Francisco Heterosexual and MSM increased by
  1.9 in past year, with MSM/IDU increasing 2.3,
  transgender by 4.4.
• Los Angeles 2007 65 MSM.
• Phoenix IDU cases slowly declining.

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2008 CEWG Reports Midwest

• Detroit IDUs account for 20, 90 Black.
• Chicago IDU by young Blacks is rare new IDUs
  are suburban Whites. Prevalence of HIV among IDU
  has declined markedly.
• St Louis 2007 79 MSM, 16 heterosexual, 4
  IDU.
• Minnesota 2007 51 MSM, 16 heterosexual, 7
  IDU, 5 MSM/IDU.

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2008 CEWG Reports East

• Philadelphia 2006 49 heterosexual, 26 MSM,
  23 IDU, 2 MSM/IDU.
• New York City PLWHA 2006 30 MSM, 21 IDU, 17
  heterosexual.
• Boston 2006 57 MSM, 5 IDU, 29 Unknown.
• Maine 2006 57 MSM, 14 IDU, 11 heterosexual,
  3 MSM/IDU.

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U.S. Treatment Admissions by Primary Substance of
Abuse 1992-2006
Source SAMHSA
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And Our Demand for Drugs Influences Drug Use in
Our Neighbors
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Primary Drug of Abuse in Mexican Border Programs
2007
Crystal 42.0
Crystal 35.1
Cocaine 22.0
Cocaine 31.8
Heroin 33.0
Heroin 15.1
Heroin 31.0
Cocaine 64.0
Heroin 31.3
Cocaine 47.4
Source SISVEA. Non Governmental Treatment
Centers. DGE. SSA. 2007
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Most Common Seized Drugs Canada
Source Office of Research and Surveillance,
Health Canada
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British Columbia
Prairie Provinces
Ontario
Quebec
Atlantic Canada
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Canadian Methamphetamine Seizures 1988-2007
Source Office of Research and Surveillance,
Health Canada
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Heroin

• 1998 Miami DMP Samples
• Southwest Asian 2.1 Pure
• Southeast Asian 2.3 Pure
• South American 19.2 Pure

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Heroin Sources and Supply Routes
SWA
Mexican
SEA
So. Amer
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Heroin as Percentage of Treatment Admissions
Toxicology Lab Exhibits US 2000-2007
Source SAMHSA, NFLIS
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Sources of Heroin Seized in US Based on Net
Weight1989-2006
DEA Heroin Signature Program
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Average Purity of Heroin Samples in the US
1992-2006
DEA Heroin Signature Program
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Heroin 101

• Black tar heroin in Texas, few mentions of
  stronger white heroin seen east of the
  Mississippi.
• Tar normally is injected but increases in
  snorting powder. Tar is cut with Benedryl,
  Dormin, Tylenol or Nytol PM, coffee creamer, etc.
  to become Brown Heroin powder.
• Increase in young inhalers statewide. If you
  snort it, its not addictive rumor.
• Treatment for young heroin users?

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Mexican Black Tar Heroin
Mexican Brown Heroin
South American Heroin
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Percent of Heroin Inhalers at Admission to Texas
Treatment Who are Hispanic 1989-June 2008
69
DSHS data analysis by JC Maxwell
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Age of Heroin Inhalers at Admission to Texas
Treatment 1989-June 2008
34
27
DSHS data analysis by JC Maxwell
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Route of Heroin Administration for Texas
Treatment Admissions 1989-June 2008
DSHS data analysis by JC Maxwell
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Heroin Admissions in Texas 2005-6/2008 by Age
Group
Source DSHS. Analysis by JC Maxwell
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US Heroin Admissions, by Route of Administration
TEDS 1992-2006
Source SAMHSA
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Primary US Heroin Admissions, by Age Group and
Route of Administration TEDS 1995 and 2005
Inhale
Inject
Source SAMHSA
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Primary US Heroin Admissions, by Race/Ethnicity
and Route of Administration TEDS 1995 and 2005
Inhale
Inject
Source SAMHSA
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Other Opiates

• OxyContin, Vicodin, Darvocet, hydrocodone,
  oxycodone, methadone, codeine, etc.

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OTHER OPIATES

• Abuse of different opiates varies by region.
• Fentanyl abuse is patches in the West, not the
  rogue powder seen in the Northeast (where heroin
  is also a white powder).
• Problem with deaths involving methadone pain
  pills (as compared to diskettes and syrup used in
  narcotic treatment programs).
• Codeine cough syrup and rap music.
• Kids and pills adults and pills.

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Other Opiate Treatment Admissions per 100,000 by
State, TEDS 1995
Range lt1-32
Incomplete data
13-25
6-9
26
10-12
lt6
Source SAMHSA
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Other Opiate Treatment Admissions per 100,000 by
State, TEDS 2000
Rangelt1-72
Incomplete data
13-25
6-9
26
10-12
lt6
Source SAMHSA
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Other Opiate Treatment Admissions per 100,000 by
State, TEDS 2006
Range 2-151
6-9
13-25
26
10-12
lt 6
Source SAMHSA
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Nonmedical Use of Pain Relievers in the Past Year
among Persons Aged 12 or Older, by Substate
Region Percentages, Annual Averages Based on
2004, 2005, and 2006 NSDUH
Source SAMHSA, 2004, 2005, 2006 NSDUH
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Source Where Pain Relievers Were Obtained for
Most Recent Nonmedical Use among Past Year Users
Aged 12 or Older NSDUH 2006
Source Where Respondent Obtained
Bought on Internet0.1
Drug Dealer/Stranger4
Other 15
Source Where Friend/Relative Obtained
More than One Doctor 2
More than One Doctor3
Free from Friend/Relative7
Free from Friend/Relative56
One Doctor 19
Bought/Took fromFriend/Relative5
OneDoctor 81
Bought/Took from Friend/Relative15
Drug Dealer/Stranger2
Other 12
1 The Other category includes the sources Wrote
Fake Prescription, Stole from Doctors
Office/Clinic/Hospital/Pharmacy, and Some Other
Way.
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Human Exposure Calls to Texas Poison Control
Centers about Methadone by Formulation 1998-2007
DSHS data analysis by JC Maxwell
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Reason for Using Prescription Pain Relievers
PATS Attitude Tracking Study 2005

• Easy to get from parents' medicine cabinets--62
• Available everywhere--52
• They are not illegal drugs--51
• Easy to get through other people's
  prescriptions--50
• Teens can claim to have a prescription if
  caught--49
• They are cheap--43
• Safer to use than illegal drugs--35
• Less shame attached to using--33
• Easy to purchase over the Internet--32
• Fewer side effects than street drugs--32
• Can be used as study aids--25
• Parents don't care as much if you get caught--21

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Non-Medical Past Year Use of Prescription Drugs
by Persons Age 12 and Over NSDUH 2005-2006
P.0S
Source NSDUH, 2006
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Cocaine
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Cocaine

• Different routes of administrationCrack vs.
  powder.
• Injecting cocaine and heroin either together or
  sequentially (Speedball)
• Risky sexual behaviors while smoking crack and
  trading drugs for sex in crack houses. Impact on
  HIV/AIDS rates.
• Methamphetamine outselling cocaine and crack in
  some areas some coke dealers now also selling
  methamphetamine to compete.
• Still around with new users. Proportion of crack
  treatment admissions who are Anglo or Hispanic
  continues to increase.

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Cocaine Purity and Percentage of Treatment
Admissions Toxicology Lab Exhibits US 2000-2007
Source SAMHSA. NFLIS
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Race-Ethnicity of US Cocaine Admissions 1992 v.
2006
Source SAMHSA
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Routes of Administration of Cocaine Admissions
TEDS 1995-2006
Source SAMHSA
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Route of Administration of Cocaine Admissions to
Treatment in US-Mexico Border Programs
Maxwell et al., 2006.
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Reefer Sadness
Marijuana
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MARIJUANA

• Fairly stable.
• Influence of Blunts and Wraps
• Use with Fry, PCP, DANK, crack, cough syrup,
  honey, etc., continues.
• Continuing references to pot and PCP and
  embalming fluid (formaldehyde).
• CJ v. Non-CJ treatment admissions

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• Primos--marijuana joint and crack.
• Fry, Amp--joint and embalming fluid (PCP?)
• Fry Sticks Fry Squares--10 each.
• Fry Sweets--blunts in embalming fluid.
• Sweet Houses--sell ready-mades.
• Candy Blunts--cigarillos in codeine cough syrup.
• Sherms--menthol cigarettes in embalming fluid.

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Texas Secondary Students Who Had Used Any
Illicit Drug in the Past Month, by Ethnicity
1988-2006
Source DSHS
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Addiction Severity Index Problems of Texans
Treated with Primary Marijuana Problem 2005
Source DSHS
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Alcohol
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Past Month Alcohol Users in the U.S. Ages 12 to
20 2005-2006
SAMHSA, The NSDUH Report Quantity and Frequency
of Alcohol Use Among Underage Drinkers, 4/2008
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Average Drinks per Day on the Days Used Alcohol
among Past Month U.S. Alcohol Users Ages 12 to
20 2005-2006
SAMHSA, The NSDUH Report Quantity and Frequency
of Alcohol Use Among Underage Drinkers, 4/2008
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Average Days of Alcohol Use among Past Month
U.S. Alcohol Users Ages 12 to 20 2005-2006
SAMHSA, The NSDUH Report Quantity and Frequency
of Alcohol Use Among Underage Drinkers, 4/2008
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Having Past Year STD among Young Adults Aged 18
to 25, by Level of Past Month Alcohol Use and
Gender NSDUH 2005
Source SAMHSA
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Past Year STD among Young Adults Aged 18 to 25,
by Past Month Alcohol and Illicit Drug Use and
Gender NSDUH 2005
Source SAMHSA
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Methamphetamine
They used to say Speed Kills?
They used to say Speed Kills?
It still does
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Methamphetamine Forms Australia
Methamphetamine Powder IDU Description
Beige/yellowy/off-white powder
Base / Paste Methamphetamine IDU Description
Oily, gunky, gluggy gel, moist, waxy
Crystalline Methamphetamine IDU Description
White/clear crystals/rocks crushed glass /
rock salt
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Yaba, Ya Ba, Ya Ma

• Pressed meth-amphetamine pills. Common in
  Cambodia, Lao PDR, Myanmar, Thailand, Viet
  Nam.
• Some mentions in the US. Similar appearance to
  Ecstasy pills, which also can contain meth.

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Methamphetamine

• Ice is defined by DEA at 80 pure MSM
  (methylsulfonylmethane) is used to cut Ice.
• Since 2004, laws limiting availability of
  pseudoephedrine have caused purity of powder and
  Ice to decrease and price to increase.
• Border seizures and Mexican laws have limited
  availability of pseudoephedrine in Mexico and
  amount of Ice imported into the US to replace
  home-cooked powder.
• Purity of gram of methamphetamine increased from
  49 in 2002 to 69 in 2005 and then decreased to
  51 in 2006.

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Primary Amphetamine/MethamphetamineTEDS
Admission Rates 1992(per 100,000 aged 12 and
over)
gt 58
35 - 58
12 - 35
lt 12
No data
Source SAMHSA
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Primary Amphetamine/MethamphetamineTEDS
Admission Rates 1997(per 100,000 aged 12 and
over)
gt 58
35 - 58
12 - 35
lt 12
No data
Source SAMHSA
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Primary Amphetamine/MethamphetamineTEDS
Admission Rates 2006(per 100,000 aged 12 and
over)
gt 58
35 - 58
12 - 35
lt 12
No data
Source SAMHSA
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Routes of Administration of Methamphetamine of
Clients in US Programs 1993-2006
Source SAMHSA
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Texas Methamphetamine Treatment Admissions 2007
(TEDS)
Source DSHS, Analysis by J C Maxwell
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ASI Scores of Texas Methamphetamine
TreatmentAdmissions 2007
Analysis by J C Maxwell
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Methamphetamine Clandestine Laboratory
Incidents and of All Substances Identified That
Were Methamphetamine in the US 1999-2007
Analysis by J C Maxwell
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US Methamphetamine Indicators 2000-2007
Analysis by J C Maxwell
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Changes in Price of Ice 2003-2008
14,500
4500
Source DEA Quarterly Intel Reports
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Characteristics of Clients Entering Treatment
with a Primary Problem with Methamphetamine/Amphet
amineUS TEDS 1993 vs. 2006
Source SAMHSA
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Los Angeles Treatment Admissions by
Race-Ethnicity 2007
SOURCE LA County ADP / CA ADP, California
Outcome Monitoring System (CalOMS), 2007.
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Spread to Other Groups

• Mention of La Tina in Texas.
• Use among day laborers, people who work long
  hours or several jobs (mentions from Hawaii).
• Mexican supply line can follow the migrant trail
  (Rohypnol).
• Sex trade Reports of Hispanic women now
  prostituting for the drug, drug/sex trade, use
  among Black male prostitutes and Black MSMs.
• Spreading in Black communities, reported more
  available.
• Shifts back and forth from cocaine (powder
  crack) to meth to cocainelonger high, price,
  meth more harmful than crack but liked it.

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Methamphetamine Admissions in U.S. and Mexican
Border States 2003
31
10
4
40
18
3
9
14
7
13
Source Maxwell et al.
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Amphetamine/Methamphetamine as of Treatment
Admissions in Mexico and the US
US
Mexico
Source Maxwell et al.
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Route of Administration of Methamphetamine
Admissions to Treatment in US-Mexico Border
Programs
Source Maxwell et al.
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• Meth abusers have trouble organizing information
  from more than one sourcecant switch points of
  view.
• Paradoxicalconcentration better when on
  methworse as become abstinentlearning memory.
• Comprehension deficits. Make sure they understand
  what counts as compliance (drug courts, CPS
  workers reuniting families, taking meds as
  scheduled). Cant remember. Need concrete and
  specific information.

Analysis by J C Maxwell
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Matrix Model

• Manualized 16 week non-residential, psychosocial
  approach used for the treatment of drug
  dependence.
• Designed to integrate several interventions into
  a comprehensive approach. Elements include
• Individual counseling
• Cognitive behavioral therapy
• Motivational interviewing
• Family education groups
• Urine testing
• Participation in 12-Step programs.

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Urinalysis Results

• Results of Ua Tests at Discharge, 6 months and 12
  Months post admission
• Matrix Group TAU Group
• D/C 66 MA-free 65 MA-free
• 6 Ms 69 MA-free 67 MA-free
• 12 Ms 59 MA-free 55 MA-free
• Over 80 follow up rate in both groups at all
  points
• Rawson, R et al Addiction vol 99, 2004

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DOWNERS

• Barbiturates (phenobarbital), benzos
  (diazepam-Valium, alprazolam-Xanax,
  clonazepam-Klonopin, lorazepam-Ativan,
  chlordiazepoxide-Librium).
• Potentiate low-quality heroin (and seen in heroin
  overdoses)
• Come down from speed or cocaine trips
• Dependence among females.
• Xanax from Mexico?
• Kids like Xanax (Four Bars).

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Club Drugs

• Problems identified early by CEWG MDMA in 1985,
  GHB in 1990,Ketamine in 1991, Rohypnol in 1993,
  but slow responses.
• Misperception that all club drugs are alike.
• CEWG members report MDMA use is up. More use by
  Blacks, low income, sex workers. Supplies through
  Canada.
• Sex risk Ketamine, GHB (Fantasy)

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Party Drugs Identified by U.S. Toxicology Labs
2000-2007
Source NFLIS
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Texas Treatment Admissions with a Primary,
Secondary or Tertiary Problem with Ecstasy
1998-2007
DSHS data analysis by JC Maxwell
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Admissions to DSHS-Funded Treatment Programs With
a 1st, 2nd, or 3rd Problem With a Club Drug 2007
Source DSHS, analysis by JC Maxwell
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Inhalants
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Texas Secondary Students Who Had Used Inhalants
Ever or in the Past Month, by Grade 2006
Source DSHS
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Texas Secondary Students Who Had Used Marijuana
Ever or in the Past Month, by Grade 2006
Source DSHS
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Texas Secondary Students Who Had Used Inhalants
Ever or in the Past Month, by Grade 2006
Source DSHS
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Percentage of Texas Students Who Had Ever Used
Inhalants, by Grade and Number of Different Types
Used 2006
Source DSHS
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Texas Reform Secondary School Students Who
Had Ever Used Specific Inhalants 2000-2001
Source DSHS
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Youths 12 to 17 Who Used Inhalants and
Experienced Major Depressive Episode (MDE) in the
Past Year, by First Inhalant Use and First MDE
NSDUH 2004-2006
Source SAMHSA
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Past Year Use of Inhalants and Major Depressive
Episodes (MDE) Number of Days Used NSDUH
2004-2006
Source SAMHSA
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Percent HIV Cases by Selected Modes of Exposure
Texas 1999-2007(Cases with Risk Not Classified
or that Seroconverted to AIDS Excluded)
Source DSHS
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Percent of Texas AIDS Cases Reported by Selected
Modes of Exposure 1987-2007(Cases with Risk Not
Classified Excluded)
Source DSHS
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Injection as Route of Administration of Clients
in Texas Programs 1988-2007
DSHS data analysis by JC Maxwell
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Past Year Injection Use of Heroin, Cocaine,
Stimulants, or Methamphetamine among Persons Aged
12 or Older, by Race/Ethnicity NSDUH
Source SAMHSA
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 Past Year Injection Drug Use among Persons Aged
12 or Older, by Geographic Characteristics
Percentages, NSDUH 2002-2005
Source SAMHSA
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Route of Administration among Past Year Illicit
Drug Users Aged 12 or Older NSDUH 2002-2005
Source SAMHSA
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Texas Male and Female HIV Cases by
Race/Ethnicity 1999-2007 (Cases that
seroconverted to AIDS excluded)
Source DSHS
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Texas Male and Female AIDS Cases by
Race/Ethnicity 1999-2007
Source DSHS
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