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| Title: | Drugs of Abuse and Trends |
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| Body: | Practitioner Diversion
Awareness Conference
Drugs of Abuse and Trends
Scott Brinks, Acting Unit chief
Liaison Unit
The following presentation was accompanied by an oral
presentation on August 6 and 7, 2018, and does not
purport to establish legal standards that are not
contained in statutes, regulations, or other competent
law. Statements contained in this presentation that are
not embodied in the law are not binding on DEA.
Summaries of statutory and regulatory provisions that
are summarized in this presentation do not purport to
state the full extent of the statutory and regulatory
requirements of the cited statutes and regulations. I
have no financial relationships to disclose.
LEGAL DISCLAIMER
U.S. Drug Enforcement Administration
Diversion Control Division
This presentation is for educational purposes only. This presentation may
not be further copied or used, with the embedded images and videos,
without an independent analysis of the application of the Fair Use
doctrine.
Fair Use
Under section 107 of the Copyright Act of 1976, allowance is made for
"Fair Use" for purposes such as criticism, comment, news reporting,
teaching, scholarship, education and research.
Fair Use is a use permitted by the copyright statute that might otherwise
be infringing. Any potentially copyrighted material used in this
presentation has been reviewed and found to be used in a manner
consistent with Fair Use. A completed Fair Use checklist is attached.
Fair Use Act Disclaimer
U.S. Drug Enforcement Administration
Diversion Control Division
§
Discuss the Public Health Epidemic.
§
Review the common drugs of abuse.
§
Discuss the relationship between
pharmaceutical controlled substances and
heroin.
Course Objectives
U.S. Drug Enforcement Administration
Diversion Control Division
§
Discuss the violence related to controlled
substance prescribing and dispensing.
§
Review key research and studies involving
the impact of indiscriminate prescribing of
controlled substances.
Course Objectives
U.S. Drug Enforcement Administration
Diversion Control Division
At the completion of this block of instruction you
will be able to answer the following questions:
1.
Which country, per million population, has
the largest amount of drug induced deaths
ages 15-64?
2.
Where does Kentucky rate in the United
States in the amount of Hydrocodone
dispensed?
Questions to Discuss
U.S. Drug Enforcement Administration
Diversion Control Division
3.
What percentage of the world's hydrocodone
production does the United States consume?
4.
What is the most misused prescription
controlled substance pain reliever in the
United States?
5.
What percent of heroin users began their
addictions with prescribed pain relievers?
Questions to Discuss
U.S. Drug Enforcement Administration
Diversion Control Division
The Problem - People Are Dying
U.S. Drug Enforcement Administration
Diversion Control Division
U.S. Drug Enforcement Administration
Diversion Control Division
The Problem - People Are Dying
The top 5 distributed scheduled controlled
substances in the United States:
1.
Hydrocodone
2.
Oxycodone
3.
Codeine
4.
Buprenorphine
5.
Morphine
Drugs of Abuse
U.S. Drug Enforcement Administration
Diversion Control Division
U.S. Drug Enforcement Administration
Office of Diversion Control
Source (2017). INCB data, International Narcotics Board: Comments on Reported Statistics on Narcotic Drugs.
United States
(Pop. 320 Mil.)
China
(Pop. 1.37 Billion)
World
(7.3 Bil)
Drug Name Percent Tons Percentage Tons Tons
Hydrocodone 99.72% 36.2 0.00% 0.001 36.3
Oxycodone 75.12% 62.5 1.08% 0.9 83.2
Morphine 48.04% 19.6 3.92% 1.6 40.8
Codeine 12.50% 35.7 2.66% 7.6 285.5
Methadone 47.11% 15.5 4.56% 1.5 32.9
Fentanyl 29.19% 0.54 0.32% 0.006 1.85
Where Does the United States
Rank In Consumption?
§
Hydrocodone / Acetaminophen (toxicity)
§
Similarities:
§
Structurally related to codeine
§
Equal to morphine in producing opiate-like
effects
§
Brand Names: Vicodin
®
, Lortab
®
, Lorcet
®
Hydrocodone
U.S. Drug Enforcement Administration
Diversion Control Division
§
October 6, 2014 moved to
SCHEDULE II
§
Street prices: $2 to $10 per tablet
depending on strength & region
Hydrocodone
U.S. Drug Enforcement Administration
Diversion Control Division
Carisoprodol
C-IV as of 1/11/2012
Benzodiazepine
Alprazolam
Muscle Relaxant
Hydrocodone
Opioid
The Trinity Cocktail
Aka: Soma
U.S. Drug Enforcement Administration
Diversion Control Division
The
1990s
OxyContin®
U.S. Drug Enforcement Administration
Diversion Control Division
OxyContin®
§
OxyContin® controlled release formulation of
Schedule II oxycodone:
§
The controlled release method of delivery
allowed for a longer duration of drug action
and contained much larger doses of
oxycodone.
§
Abusers easily compromised the controlled
release formulation by crushing the tablets for
a powerful morphine-like high.
§
10, 20, 40, 80mg available.
U.S. Drug Enforcement Administration
Diversion Control Division
§
Effects:
§
Similar to morphine in effects and
potential for abuse/dependence.
§
Sold in "Cocktails" such as:
§
Oxycodone, Soma ® and Xanax®
§
Street price: Approx. $80 per 80mg tablet
OxyContin®
U.S. Drug Enforcement Administration
Diversion Control Division
Drug Trends
U.S. Drug Enforcement Administration
Diversion Control Division
Heroin and Fentanyl
U.S. Drug Enforcement Administration
Diversion Control Division
Heroin
.
Heroin comes from the poppy flower.
.
It comes from outside of the U.S. - Asia,
Pakistan, Afghanistan.
.
Brought in through different drug routes -
Mexico.
.
Heroin use has increased in the last 5 years.
U.S. Drug Enforcement Administration
Diversion Control Division
Fentanyl
§
Fentanyl is a synthetic opioid.
§
Fentanyl is very powerful (50-100 times more potent
than heroin).
§
Dealers are combining Fentanyl with Heroin, pills,
marijuana, counterfeit pills, etc.
§
Carfentanil (100 times more potent than Fentanyl).
§
Is stolen or diverted from legitimate channels.
U.S. Drug Enforcement Administration
Diversion Control Division
Illicit Fentanyl and
Precursors Flow Origination
in China
Fentanyl
U.S. Drug Enforcement Administration
Diversion Control Division
Fentanyl
§
Is purchased from China and shipped directly to
the United States or smuggled through Mexico.
§
May 2015 Chinese
Customs seized 46 Kilos
of Fentanyl and 26 Kilos
of acetyl fentanyl.
§
6 customs officers
became ill
§
1 in a coma after
handling.
U.S. Drug Enforcement Administration
Diversion Control Division
Fentanyl
§
Produced in clandestine labs in the United
States.
§
DEA LA Field Division
§
Residential location
§
3 pill presses
§
Powder mixing
equipment
§
Ventilation equipment
U.S. Drug Enforcement Administration
Diversion Control Division
Lethal Dose
Fentanyl
Heroin Fentanyl Carfentanil
U.S. Drug Enforcement Administration
Diversion Control Division
§
Be cautious when inventorying personal items in ED
or the hospital.
§
Be cautious when touching patients.
§
Be cautions when going through a patient's personal
items.
§
Don't ever take back a patient's medications.
Fentanyl Dangers to
Practitioners
U.S. Drug Enforcement Administration
Diversion Control Division
From Pills to Heroin
U.S. Drug Enforcement Administration
Diversion Control Division
§
75% of heroin users switched after first
using controlled substance prescription
pain relievers.
§
Heroin is much cheaper than prescription
drugs.
§
Deck: 1 small bag of heroin ($8 to $10)
§
Bundle: 10 bags of heroin
From Pills to Heroin
U.S. Drug Enforcement Administration
Diversion Control Division
Prescription Drug Abuse Trends
U.S. Drug Enforcement Administration
Diversion Control Division
Prescription Drug Abuse
Is Driven By-
Indiscriminate Prescribing And
Criminal Activity
U.S. Drug Enforcement Administration
Diversion Control Division
Hydrocodone
, 41%
Oxycodone
, 23%
Codeine, 16%
Tramadol,
10%
Buprenorphine,
4%
Morphine,
3%
Methadone,
2%
Fentanyl, 1%
Prescription Pain Reliever Misuse
(Age 12 and Older)(2016)
Source: National Survey On Drug Use and Health (2016)
Total past year
abusers: 11,517,000
U.S. Drug Enforcement Administration
Diversion Control Division
Practition
ers, 36%
Friend or
Relative,
54%
Drug
Dealer,
Stranger,
5%
Other, 5%
Where Do They Come From?
U.S. Drug Enforcement Administration
Office of Diversion Control
Source: Department of Health and Human Services
Many Patients Share Prescribed
Controlled Substances
University of Pennsylvania Dental School Study:
§
*More than half of the narcotics prescribed for
wisdom teeth removal go unused...findings
suggest that more than 100 million pills
prescribed go unused... leaving the door open
for possible misuse or abuse.
Source: https://www.pennmedicine.org/news/news-
releases/2016/september/100-million-prescription-opioid
https://www.nlm.nih.gov/medlineplus/news/fullstory_159336.html
U.S. Drug Enforcement Administration
Diversion Control Division
John Hopkins Study:
§
+60% had leftover opioids they hung on for
"future use"
§
20% shared their medications
§
8% likely will share w/ friend
§
14% likely will share w/ relative
§
>10% securely lock their medication
Source: https://www.pennmedicine.org/news/news-
releases/2016/september/100-million-prescription-opioid
https://www.nlm.nih.gov/medlineplus/news/fullstory_159336.html
Many Patients Share Prescribed
Controlled Substances
U.S. Drug Enforcement Administration
Office of Diversion Control
John Hopkins Study:
§
The study further explored adult
attitudes towards controlled substances
and found:
§
73 percent of adults agreed that children
can overdose on opioids more easily than
adults.
Source: https://www.pennmedicine.org/news/news-
releases/2016/september/100-million-prescription-opioid
https://www.nlm.nih.gov/medlineplus/news/fullstory_159336.html
Many Patients Share Prescribed
Controlled Substances
U.S. Drug Enforcement Administration
Office of Diversion Control
John Hopkins Study:
§
Yet found that 13% of the respondents
"worry" about their children accessing their
opioid medications.
§
With parents of older children reporting
that they were significantly less likely to
worry about children accessing medications
than parents of younger children.
Source: https://www.pennmedicine.org/news/news-
releases/2016/september/100-million-prescription-opioid
https://www.nlm.nih.gov/medlineplus/news/fullstory_159336.html
Many Patients Share Prescribed
Controlled Substances
U.S. Drug Enforcement Administration
Office of Diversion Control
Violence
U.S. Drug Enforcement Administration
Diversion Control Division
Violence Associated
With Opiates
Communities undergo:
§
Drug related crimes
a. Robberies
b. Burglaries/break ins
c. Drug thefts
§
Abuse and neglect of children
§
Domestic violence in the home
§
Increase of arrests
U.S. Drug Enforcement Administration
Diversion Control Division
50.0%
36.0%
7.7%
4.3%
Source: DTL
Date Prepared: 07/19/2018
Lost in Transit
341 Dosage Units
Night Break-In
615 Dosage Units
Nationwide Practitioners Thefts in Dosage Units
January 1, 2009 - December 31, 2017
Other
3,973 Dosage Units
Employee Pilferage
2,860 Dosage Units
Customer Theft
136 Dosage Units - 1.7%
Armed Robbery
21 Dosage Units - 0.3%
39
U.S. Drug Enforcement Administration
Diversion Control Division
45%
35%
18%
2%
Source: DTL
Date Prepared: 07/19/2018
Lost in Transit
2 Dosage Units
Night Break-In
15 Dosage Units
Kentucky Practitioner Thefts in Dosage Units
January 1, 2009 - December 31, 2017
Other
39 Dosage Units
Employee Pilferage
30 Dosage Units
40
U.S. Drug Enforcement Administration
Diversion Control Division
CDC Guidelines
Prescribing Opioids for Chronic Pain
Clinical Reminders:
§
Opioids are not first-line or routine therapy for
chronic pain.
§
Establish and measure goals for pain and
function.
§
Discuss benefits, risks and availability of non
opioid therapies with patients.
Source: CDC Morbidity & Mortality Weekly Report CDC
Guideline for Prescribing Opioids for Chronic Pain -
United States, 2016, March 15, 2016
www.cdc.gov/drugoverdose/prescribing/guideline.html
U.S. Drug Enforcement Administration
Diversion Control Division
Clinical Reminders:
§
Use immediate-release opioids when starting.
§
Start low and go slow.
§
When opioids are needed for acute pain,
prescribe no more than needed.
CDC Guidelines
Prescribing Opioids for Chronic Pain
Source: CDC Morbidity & Mortality Weekly Report CDC
Guideline for Prescribing Opioids for Chronic Pain -
United States, 2016, March 15, 2016
www.cdc.gov/drugoverdose/prescribing/guideline.html
U.S. Drug Enforcement Administration
Diversion Control Division
Clinical Reminders:
§
Do not prescribe ER/LA opioids for acute pain.
§
Follow-up and re-evaluate risk of harm; reduce
dose or taper and discontinue if needed.
§
Evaluate risk factors for opioid-related harms.
CDC Guidelines
Prescribing Opioids for Chronic Pain
Source: CDC Morbidity & Mortality Weekly Report CDC
Guideline for Prescribing Opioids for Chronic Pain -
United States, 2016, March 15, 2016
www.cdc.gov/drugoverdose/prescribing/guideline.html
U.S. Drug Enforcement Administration
Diversion Control Division
Clinical Reminders:
§
Check PDMP for higher dosages and prescriptions from
other providers.
§
Use urine drug testing to identify prescribed substances
and undisclosed use.
§
Avoid concurrent benzodiazepine and opioid prescribing.
§
Arrange treatment for opioid use disorder if needed.
CDC Guidelines
Prescribing Opioids for Chronic Pain
Source: CDC Morbidity & Mortality Weekly Report CDC
Guideline for Prescribing Opioids for Chronic Pain -
United States, 2016, March 15, 2016
www.cdc.gov/drugoverdose/prescribing/guideline.html
U.S. Drug Enforcement Administration
Diversion Control Division
Survey of Long-Term
Painkiller Users
§
Majority say their doctor talked about possibility
of addiction or dependence - 61% say there was no
discussion about plan to get them off.
§
Majority say they used the drugs to relieve pain.
Other major reasons for taking them:
§
20% - 'for fun or get high"
§
14% - "to deal with day-to-day stress"
§
10% - "to relax or relieve tension"
Source: Washington Post/Kaiser Family Foundation
Survey of Long-Term Prescription Painkiller Users and
Their Household Members, December 2016
U.S. Drug Enforcement Administration
Diversion Control Division
Survey of Long-Term
Painkiller Users
§
Other Findings:
§
34% admit being dependent or addicted.
§
17% have taken painkillers that were not
specifically prescribed for them.
§
14% have given their painkillers to a family
member or friend.
§
20% know or suspect someone was using, taking
or selling their painkillers.
Source: Washington Post/Kaiser Family Foundation
Survey of Long-Term Prescription Painkiller Users and
Their Household Members, December 2016
U.S. Drug Enforcement Administration
Diversion Control Division
1.
Which country, per million population, has
the largest amount of drug induced deaths
ages 15-64?
A.
Sweden
B.
Germany
C.
United States
D.
Russia
E.
China
Post Questions
U.S. Drug Enforcement Administration
Diversion Control Division
2.
Where does Kentucky rate in the United
States in the amount of Hydrocodone
dispensed?
A.
15th
B.
48th
C.
2nd
D.
25th
Post Questions
U.S. Drug Enforcement Administration
Diversion Control Division
3.
What percentage of the world's
hydrocodone production does the United
States consume?
A.
Less than 10%
B.
34%
C.
50%
D.
More than 70%
Post Questions
U.S. Drug Enforcement Administration
Diversion Control Division
4.
What is the most misused prescription
controlled substance pain reliever in the
United States?
A.
Oxycodone
B.
Morphine
C.
Hydrocodone
D.
Codeine
Post Questions
U.S. Drug Enforcement Administration
Diversion Control Division
5.
What percent of heroin users began their
addictions with prescribed pain relievers?
A.
15%
B.
40%
C.
75%
D.
90%
E.
99%
Post Questions
U.S. Drug Enforcement Administration
Diversion Control Division
Thank-you for your time
and attention !
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