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Body:Practitioner Diversion Awareness Conference Drugs of Abuse and Trends Scott Brinks, Unit Chief Liaison Unit

The following presentation was accompanied by an oral presentation on November 18-19, 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 Tennessee rate in the United States in the amount of Oxycodone 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

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Hydrocodone Distribution 2012-2017 U.S. Totals Schedule Change TOTAL DOSAGES Drug Enforcement Administration, Diversion Control Division, Pharmaceutical Investigations Section, Targeting and Analysis Unit Source: ARCOS Date Prepared: 07/19/2018 U.S. Drug Enforcement Administration Diversion Control Division

NY WA OR MT ID WY ND SD MN IA NE WI MI CO KS MO IL IN UT NV CA AZ NM OK TX AK AR LA TN KY MS AL GA SC NC OH VA PA ME V T N J MD RI DC DE HI V W FL H N PR Purchases of Hydrocodone for January - December, 2017 U.S. Average: 64,540 Dosage Units Above Average = 80,676 Dosage Units or more Average = 48,405 - 80,675 Dosage Units Below Average = 48,404 Dosage Units or less Zero Dosage Units U.S. Drug Enforcement Administration Diversion Control Division

Hydrocodone Distribution Retail Pharmacies U.S. Drug Enforcement Administration Diversion Control Division

* Business Activity - Retail Pharmacies State Ranking Average Per 100K Population* Hydrocodone January - December 2017 Source: Drug Enforcement Administration, Office of Diversion Control, Pharmaceutical Investigations Section, Targeting and Analysis Unit Most current ARCOS information as of 08/27/2016 RANK STATE TOTAL RANK STATE TOTAL RANK STATE TOTAL RANK STATE TOTAL RANK STATE TOTAL 1 AL 3,585,414 12 WV 2,424,836 23 WA 1,625,707 34 AK 1,111,009 45 NH 592,446 2 KY 3,535,589 13 MO 2,406,644 24 UT 1,585,094 35 ME 1,105,895 46 DE 557,548 3 OK 3,398,390 14 SC 2,255,782 25 WY 1,571,219 36 PA 1,080,254 47 MD 496,208 4 AR 3,326,004 15 KS 2,249,494 26 NC 1,549,791 37 VA 1,040,001 48 CT 459,564 5 MI 3,091,718 16 OR 2,046,284 27 NE 1,545,596 38 ND 1,034,321 49 MA 421,066 6 TN 2,820,611 17 MT 1,890,027 28 OH 1,471,403 39 CO 1,001,671 50 NJ 309,888 7 IN 2,783,355 18 IL 1,860,998 29 FL 1,445,816 40 HI 939,533 51 VI 216,162 8 MS 2,740,074 19 GA 1,855,116 30 SD 1,412,448 41 RI 887,156 52 DC 191,666 9 ID 2,655,726 20 CA 1,828,560 31 AZ 1,315,144 42 MN 808,733 53 GU 57,614 10 LA 2,487,009 21 TX 1,799,909 32 NM 1,303,919 43 NY 697,852 54 PR 7,541 11 NV 2,453,626 22 IA 1,663,082 33 WI 1,242,285 44 VT 646,581 55 AS 0 U.S. Drug Enforcement Administration Diversion Control Division

Hydrocodone Distribution Practitioner's Office U.S. Drug Enforcement Administration Diversion Control Division

* Business Activity - Retail Practitioners Source: Drug Enforcement Administration, Office of Diversion Control, Pharmaceutical Investigations Section, Targeting and Analysis Unit Most current ARCOS information as of 08/27/2016 State Ranking Average Per 100K Population* Hydrocodone January - December 2017 RANK STATE TOTAL RANK STATE TOTAL RANK STATE TOTAL RANK STATE TOTAL RANK STATE TOTAL 1 HI 26,998 12 VA 6,373 23 IA 3,990 34 IN 2,497 45 DE 1,626 2 GA 10,390 13 CO 6,293 24 NE 3,923 35 RI 2,261 46 VT 1,582 3 WY 9,777 14 ID 6,031 25 CT 3,846 36 GU 2,242 47 AR 1,531 4 IL 8,439 15 AK 5,728 26 KY 3,699 37 ME 2,198 48 SC 1,437 5 ND 8,339 16 AZ 5,656 27 MN 3,282 38 KS 2,133 49 NM 1,354 6 MD 7,904 17 FL 4,894 28 WI 3,224 39 NY 2,028 50 VI 1,275 7 NV 7,736 18 WA 4,790 29 UT 3,126 40 OH 1,999 51 MS 711 8 MO 7,640 19 TN 4,770 30 NJ 3,044 41 TX 1,971 52 DC 665 9 CA 7,619 20 MT 4,618 31 PA 2,677 42 MA 1,952 53 NH 304 10 AL 7,493 21 OR 4,435 32 LA 2,595 43 NC 1,845 54 AS 0 11 OK 7,188 22 MI 4,134 33 WV 2,558 44 SD 1,756 55 PR 0 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® OxyContin® U.S. Drug Enforcement Administration Diversion Control Division

OxyContin® U.S. Drug Enforcement Administration Diversion Control Division

. Street price: Approx. $80 per 80mg tablet . 90 tabs prescribed a month = . $7200 a month income. . $85,400 year.

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Oxycodone Distribution 2012-2017 U.S. Totals TOTAL DOSAGES U.S. Drug Enforcement Administration Diversion Control Division

Hydrocodone Schedule Change

NY WA OR MT ID WY ND SD MN IA NE WI MI CO KS MO IL IN UT NV CA AZ NM OK TX AK AR LA TN KY MS AL GA SC NC OH VA PA ME V T N J MD RI DC DE HI V W FL H N PR Purchases of Oxycodone for January - December, 2017 U.S. Average: 59,777 Dosage Units Above Average = 74,722 Dosage Units or more Average = 44,833 - 74,721 Dosage Units Below Average = 44,832 Dosage Units or less Zero Dosage Units U.S. Drug Enforcement Administration Diversion Control Division

Oxycodone Distribution Retail Pharmacies U.S. Drug Enforcement Administration Diversion Control Division

* Business Activity - Retail Pharmacies State Ranking Average Per 100K Population* Oxycodone January - December 2017 Source: Drug Enforcement Administration, Office of Diversion Control, Pharmaceutical Investigations Section, Targeting and Analysis Unit Most current ARCOS information as of 08/27/2016 RANK STATE TOTAL RANK STATE TOTAL RANK STATE TOTAL RANK STATE TOTAL RANK STATE TOTAL 1 TN 2,482,592 12 OK 1,839,943 23 CO 1,554,308 34 ID 1,355,169 45 NE 905,312 2 DE 2,434,971 13 KY 1,818,568 24 AR 1,541,811 35 VA 1,346,683 46 ND 808,939 3 AZ 2,352,252 14 SC 1,800,677 25 GA 1,531,508 36 RI 1,325,984 47 SD 775,352 4 NC 2,241,355 15 FL 1,752,355 26 CT 1,508,377 37 IN 1,294,177 48 IA 727,506 5 NV 2,107,348 16 NJ 1,713,680 27 ME 1,504,762 38 VT 1,254,978 49 CA 702,075 6 OR 2,090,375 17 MO 1,692,212 28 KS 1,503,406 39 NY 1,247,762 50 IL 390,897 7 UT 1,999,527 18 AL 1,613,912 29 MA 1,447,599 40 MS 1,234,640 51 TX 347,257 8 PA 1,993,744 19 NH 1,608,169 30 AK 1,434,069 41 MN 1,209,213 52 VI 233,462 9 MD 1,980,787 20 WY 1,590,384 31 LA 1,407,671 42 HI 1,047,703 53 PR 213,579 10 WA 1,851,057 21 WV 1,561,628 32 WI 1,385,132 43 DC 982,924 54 GU 201,031 11 OH 1,840,437 22 NM 1,557,335 33 MT 1,357,073 44 MI 915,989 55 AS 0 U.S. Drug Enforcement Administration Diversion Control Division

Oxycodone Distribution Practitioner's Office U.S. Drug Enforcement Administration Diversion Control Division

* Business Activity - Retail Practitioners Source: Drug Enforcement Administration, Office of Diversion Control, Pharmaceutical Investigations Section, Targeting and Analysis Unit Most current ARCOS information as of 08/27/2016 State Ranking Average Per 100K Population* Oxycodone January - December 2017 RANK STATE TOTAL RANK STATE TOTAL RANK STATE TOTAL RANK STATE TOTAL RANK STATE TOTAL 1 HI 15,309 12 NE 1,118 23 NY 489 34 NM 228 45 RI 86 2 NV 6,877 13 ND 1,079 24 MI 442 35 AR 223 46 TX 71 3 MD 5,964 14 OK 1,047 25 NJ 427 36 UT 218 47 VT 64 4 CT 4,781 15 IA 1,031 26 CA 419 37 ME 211 48 KY 46 5 GA 3,296 16 MN 1,015 27 PA 384 38 NC 203 49 DE 37 6 CO 3,185 17 AZ 946 28 IL 372 39 OH 198 50 NH 15 7 AL 2,517 18 OR 825 29 WY 362 40 MS 183 51 WV 11 8 WI 2,091 19 VA 764 30 DC 332 41 IN 135 52 AS 0 9 ID 1,491 20 KS 613 31 SD 332 42 MT 131 53 GU 0 10 TN 1,276 21 FL 599 32 MO 306 43 MA 109 54 PR 0 11 AK 1,195 22 SC 560 33 WA 264 44 LA 108 55 VI 0 U.S. Drug Enforcement Administration Diversion Control Division

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Codeine Distribution 2012-2017 U.S. Totals TOTAL DOSAGES Source: ARCOS Date Prepared: 07/19/2018 Hydrocodone Schedule Change U.S. Drug Enforcement Administration Diversion Control Division

NY WA OR MT ID WY ND SD MN IA NE WI MI CO KS MO IL IN UT NV CA AZ NM OK TX AK AR LA TN KY MS AL GA SC NC OH VA PA ME V T N J MD RI DC DE HI V W FL H N PR Purchases of Codeine for January - December, 2017 U.S. Average: 7,931 Dosage Units Above Average = 9,915 Dosage Units or more Average = 5,948 - 9,914 Dosage Units Below Average = 5,947 Dosage Units or less Zero Dosage Units U.S. Drug Enforcement Administration Diversion Control Division

Codeine Distribution Retail Pharmacies U.S. Drug Enforcement Administration Diversion Control Division

* Business Activity - Retail Pharmacies State Ranking Average Per 100K Population* Codeine January - December 2017 Source: Drug Enforcement Administration, Office of Diversion Control, Pharmaceutical Investigations Section, Targeting and Analysis Unit Most current ARCOS information as of 08/27/2016 RANK STATE TOTAL RANK STATE TOTAL RANK STATE TOTAL RANK STATE TOTAL RANK STATE TOTAL 1 TX 558,944 12 KY 160,788 23 MS 131,527 34 ID 114,898 45 WY 100,776 2 MI 339,570 13 DE 158,838 24 FL 130,259 35 IN 113,251 46 VA 100,235 3 AR 326,690 14 AZ 156,606 25 WI 130,170 36 MN 110,948 47 NE 96,768 4 OK 298,568 15 GA 155,329 26 MT 130,051 37 ND 110,332 48 GU 88,326 5 DC 280,465 16 PA 155,022 27 OR 128,007 38 VI 108,354 49 NH 88,175 6 SC 258,727 17 MD 149,039 28 WA 127,937 39 NY 105,322 50 VT 83,141 7 WV 227,039 18 AL 146,346 29 OH 127,877 40 MA 105,180 51 UT 78,268 8 TN 199,376 19 KS 141,762 30 SD 127,396 41 RI 103,770 52 NC 75,611 9 IL 194,399 20 NV 134,291 31 HI 125,737 42 AK 103,396 53 CO 66,449 10 CA 179,625 21 NJ 133,024 32 NM 118,756 43 IA 102,874 54 PR 55,592 11 MO 168,685 22 LA 131,654 33 ME 118,450 44 CT 101,766 55 AS 0 U.S. Drug Enforcement Administration Diversion Control Division

Codeine Distribution Practitioner's Office U.S. Drug Enforcement Administration Diversion Control Division

* Business Activity - Retail Practitioners Source: Drug Enforcement Administration, Office of Diversion Control, Pharmaceutical Investigations Section, Targeting and Analysis Unit Most current ARCOS information as of 08/27/2016 State Ranking Average Per 100K Population* Codeine January - December 2017 RANK STATE TOTAL RANK STATE TOTAL RANK STATE TOTAL RANK STATE TOTAL RANK STATE TOTAL 1 PA 9,030 12 OK 1,723 23 NY 932 34 SD 393 45 WV 194 2 MD 5,841 13 TN 1,571 24 ND 862 35 GU 392 46 VI 182 3 WA 4,279 14 AL 1,539 25 AR 723 36 LA 390 47 NM 167 4 ID 4,170 15 GA 1,538 26 MT 703 37 WI 389 48 MS 108 5 CA 3,806 16 WY 1,265 27 TX 645 38 DC 332 49 OH 105 6 OR 3,794 17 HI 1,219 28 MA 603 39 NV 331 50 NC 64 7 VA 3,013 18 IL 1,198 29 DE 565 40 FL 285 51 VT 56 8 NE 2,609 19 KS 1,168 30 ME 467 41 IN 239 52 NH 39 9 AZ 2,454 20 MI 941 31 KY 449 42 CT 238 53 AS 0 10 NJ 2,352 21 MN 941 32 IA 440 43 UT 235 54 PR 0 11 MO 2,040 22 CO 935 33 AK 428 44 SC 196 55 RI 0 U.S. Drug Enforcement Administration Diversion Control Division

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Hydrocodone Schedule Change Buprenorphine Distribution 2012-2017 U.S. Totals TOTAL DOSAGES Source: ARCOS Date Prepared: 07/19/2018 U.S. Drug Enforcement Administration Diversion Control Division

NY WA OR MT ID WY ND SD MN IA NE WI MI CO KS MO IL IN UT NV CA AZ NM OK TX AK AR LA TN KY MS AL GA SC NC OH VA PA ME V T N J MD RI DC DE HI V W FL H N PR Purchases of Buprenorphine for January - December, 2017 U.S. Average: 7,192 Dosage Units Above Average = 8,991 Dosage Units or more Average = 5,394 - 8,990 Dosage Units Below Average = 5,393 Dosage Units or less Zero Dosage Units U.S. Drug Enforcement Administration Diversion Control Division

Buprenorphine Distribution Retail Pharmacies U.S. Drug Enforcement Administration Diversion Control Division

* Business Activity - Retail Pharmacies State Ranking Average Per 100K Population* Buprenorphine January - December 2017 Source: Drug Enforcement Administration, Office of Diversion Control, Pharmaceutical Investigations Section, Targeting and Analysis Unit Most current ARCOS information as of 08/27/2016 RANK STATE TOTAL RANK STATE TOTAL RANK STATE TOTAL RANK STATE TOTAL RANK STATE TOTAL 1 VT 436,048 12 CT 217,275 23 IN 159,146 34 MT 110,046 45 IL 61,765 2 KY 407,009 13 LA 215,372 24 OK 154,844 35 AR 105,607 46 CA 60,115 3 WV 398,890 14 MD 214,742 25 MI 151,375 36 HI 97,804 47 TX 57,735 4 ME 376,757 15 DC 200,353 26 WA 150,098 37 WI 90,170 48 KS 47,550 5 RI 361,231 16 UT 190,899 27 NY 148,466 38 GA 85,588 49 NE 37,191 6 MA 322,898 17 NM 172,452 28 OR 139,886 39 MO 84,972 50 PR 32,169 7 NH 320,500 18 MS 169,449 29 FL 128,596 40 AZ 78,512 51 SD 28,934 8 TN 280,492 19 NJ 163,796 30 VA 126,434 41 CO 74,861 52 IA 25,548 9 AL 254,742 20 NC 162,615 31 ID 118,328 42 MN 72,696 53 VI 7,148 10 PA 251,184 21 DE 160,834 32 SC 114,690 43 NV 68,093 54 GU 269 11 OH 226,748 22 AK 160,797 33 WY 113,050 44 ND 66,964 55 AS 0 U.S. Drug Enforcement Administration Diversion Control Division

Buprenorphine Distribution Practitioner's Office U.S. Drug Enforcement Administration Diversion Control Division

* Business Activity - Retail Practitioners Source: Drug Enforcement Administration, Office of Diversion Control, Pharmaceutical Investigations Section, Targeting and Analysis Unit Most current ARCOS information as of 08/27/2016 State Ranking Average Per 100K Population* Buprenorphine January - December 2017 RANK STATE TOTAL RANK STATE TOTAL RANK STATE TOTAL RANK STATE TOTAL RANK STATE TOTAL 1 MD 1,912 12 WA 197 23 CO 45 34 MA 6 45 GU 0 2 PA 1,902 13 OH 147 24 ND 40 35 LA 5 46 HI 0 3 NV 1,694 14 AK 132 25 TN 36 36 RI 5 47 ID 0 4 MI 887 15 AZ 116 26 NH 32 37 WV 5 48 IA 0 5 NM 659 16 SC 100 27 VA 27 38 ME 3 49 MT 0 6 OR 556 17 KS 95 28 KY 22 39 CT 2 50 NE 0 7 NJ 520 18 NY 93 29 IN 20 40 MS 2 51 PR 0 8 TX 356 19 AL 71 30 MN 19 41 UT 2 52 SD 0 9 CA 325 20 GA 61 31 NC 19 42 AS 0 53 VT 0 10 FL 268 21 MO 53 32 IL 11 43 AR 0 54 VI 0 11 WI 239 22 OK 52 33 DE 7 44 DC 0 55 WY 0 U.S. Drug Enforcement Administration Diversion Control Division

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Morphine Distribution 2012-2017 U.S. Totals TOTAL DOSAGES Source: ARCOS Date Prepared: 07/19/2018 U.S. Drug Enforcement Administration Diversion Control Division

Hydrocodone Schedule Change

NY WA OR MT ID WY ND SD MN IA NE WI MI CO KS MO IL IN UT NV CA AZ NM OK TX AK AR LA TN KY MS AL GA SC NC OH VA PA ME V T N J MD RI DC DE HI V W FL H N PR Purchases of Morphine for January - December, 2017 U.S. Average: 9,245 Dosage Units Above Average = 11,557 Dosage Units or more Average = 6,934 - 11,556 Dosage Units Below Average = 6,933 Dosage Units or less Zero Dosage Units Source: ARCOS Date Prepared: 07/19/2018 U.S. Drug Enforcement Administration Diversion Control Division

Morphine Distribution Retail Pharmacies U.S. Drug Enforcement Administration Diversion Control Division

* Business Activity - Retail Pharmacies State Ranking Average Per 100K Population* Morphine January - December 2017 Source: Drug Enforcement Administration, Office of Diversion Control, Pharmaceutical Investigations Section, Targeting and Analysis Unit Most current ARCOS information as of 08/27/2016 RANK STATE TOTAL RANK STATE TOTAL RANK STATE TOTAL RANK STATE TOTAL RANK STATE TOTAL 1 AZ 379,991 12 MI 246,764 23 AL 198,989 34 LA 155,827 45 CT 127,781 2 OK 351,037 13 AR 233,779 24 CO 198,616 35 IA 148,426 46 NJ 120,539 3 DE 349,488 14 VT 218,336 25 SC 194,582 36 WV 148,306 47 ND 118,014 4 TN 335,755 15 PA 218,043 26 ME 191,026 37 KY 145,630 48 TX 107,496 5 NV 334,876 16 WI 209,121 27 HI 184,522 38 NE 143,139 49 IL 102,821 6 OR 315,481 17 AK 207,505 28 NC 181,681 39 OH 142,834 50 NY 101,085 7 FL 279,274 18 WY 204,948 29 IN 177,193 40 SD 137,390 51 DC 65,809 8 ID 271,764 19 MD 202,595 30 NM 175,526 41 MA 137,048 52 GU 48,198 9 WA 256,695 20 NH 201,007 31 CA 163,511 42 RI 136,495 53 VI 15,297 10 UT 256,130 21 KS 200,965 32 MS 158,679 43 MN 132,492 54 PR 3,870 11 MT 255,527 22 MO 200,467 33 GA 158,502 44 VA 131,301 55 AS 0 U.S. Drug Enforcement Administration Diversion Control Division

Morphine Distribution Practitioner's Office U.S. Drug Enforcement Administration Diversion Control Division

* Business Activity - Retail Practitioners Source: Drug Enforcement Administration, Office of Diversion Control, Pharmaceutical Investigations Section, Targeting and Analysis Unit Most current ARCOS information as of 08/27/2016 State Ranking Average Per 100K Population* Morphine January - December 2017 RANK STATE TOTAL RANK STATE TOTAL RANK STATE TOTAL RANK STATE TOTAL RANK STATE TOTAL 1 HI 1,449 12 CO 90 23 CA 32 34 OR 10 45 LA 0 2 MD 973 13 FL 76 24 NY 30 35 IN 8 46 ME 0 3 OK 938 14 AK 63 25 TN 23 36 MN 6 47 MS 0 4 NV 797 15 KS 61 26 MO 22 37 NJ 6 48 NH 0 5 AL 546 16 MI 55 27 SC 19 38 NE 5 49 ND 0 6 CT 539 17 WY 53 28 KY 16 39 NM 5 50 PR 0 7 GA 402 18 DE 42 29 PA 15 40 TX 5 51 RI 0 8 ID 270 19 WA 42 30 NC 14 41 IL 4 52 SD 0 9 WI 158 20 AZ 41 31 MA 11 42 AS 0 53 VT 0 10 UT 107 21 MT 40 32 IA 10 43 DC 0 54 VI 0 11 VA 104 22 AR 34 33 OH 10 44 GU 0 55 WV 0 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 . The raw material (opium) to manufacture heroin comes from the poppy plant. . The raw material (opium) comes from outside of the U.S. - Asia, Pakistan, Afghanistan. . Heroin comes in through different drug routes - primarily through 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). § Carfentanil 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: 04/19/2018 Lost in Transit 341 Thefts Night Break-In 615 Thefts Nationwide Practitioners Thefts January 1, 2009 - December 31, 2017 Other 3,973 Thefts Employee Pilferage 2,860 Thefts Customer Theft 136 Thefts - 1.7% Armed Robbery 21 Thefts - 0.3% U.S. Drug Enforcement Administration Diversion Control Division

64% 26% 5% 4% Source: DTL Date Prepared: 04/19/2018 Lost in Transit 12 Thefts Night Break-In 16 Thefts Tennessee Practitioner Thefts January 1, 2009 - December 31, 2017 Employee Pilferage 205 Thefts Other 84 Thefts Customer Theft 2 Thefts 1% 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 Tennessee rate in the United States in the amount of Oxycodone dispensed? A. 15th B. 48th C. 1st 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

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