Prescription Pain Medications and Heroin: A Changing Picture Jane Maxwell, Ph.D. Center for Social Work Research The University of Texas at Austin Disclosure to Participants Commercial Support: This educational activity received no commercial support. Disclosure of Conflict of Interest The speaker discloses no conflict of interest. Shifting Between Opiate Pills and Heroin Pollini et al. found high proportion of young heroin injectors reported problematic prescription–type opioid use before initiating heroin use. NSDUH study from 2002-2011 found 80% who began heroin use in past year (recent initiates) had previous non-medical use of pain relievers. Only 1% of recent initiates reported heroin use prior to using pain relievers. Pollini R. et al. Problematic use of prescription type opioids prior to heroin use among young heroin injectors. Sub Abuse and Rehab, 173-180, 2011. Muhuri P. et al. Associations of Nonmedical Pain Reliever Use and Initiation of Heroin Use in the United States. CBMSQ Data Review, SAMHSA, August 3 2013 Jane Maxwell, UT Addiction Research Institute, 512 232-0610
THE GOOD NEWS & BAD NEWS • Most shifting from other opiates to heroin. • Trends in demand, supply, and unintended consequences heading down (impact of actions by FDA and by manufacturers, and overdose campaigns). IDU risks heading up. • Changes in users (young suburban heroin users and aging adults dependent on pain pills and benzos). • Treatment need vs. capacity. • Unresolved problems in increasing accessibility to treatment. Data Sources • Deaths: CDC Wonder—deaths categorized by ICD Code • Treatment: admissions from SAMHSA’s Treatment Episode Data Set • Forensic Toxicology Labs: Items identified in labs which report to DEA’s National Forensic Laboratory System • Poison center cases: From American Association of Poison Control Center Annual Reports 5 Human Exposure Cases Reported by Poison Centers in the US: AAPCC 2004-2012 35000 30000 25000 Hydrocodone # Cases 20000 Oxycodone Cocaine 15000 Methadone Heroin 10000 5000 0 2004 2005 2006 2007 2008 2009 2010 2011 2012 Annual Reports of the American Association of Poison Control Centers 2004-2012 Jane Maxwell, UT Addiction Research Institute, 512 232-0610
Percentage of Items Identified in DEA’s NFLIS Laboratory System: 2005-2014 14 12 10 % of Items Seized Heroin 8 Oxycodone Hydrocodone 6 Methadone 4 2 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 DEA’s National Forensic Laboratory System, data retrieved 9/19/14 Grams of Selected Drugs Distributed per 100,000: DEA ARCOS 1997-2013 70,000,000 800 Hydrocodone, Oxycodone, Methadone 700 60,000,000 600 50,000,000 Buprenorphine 500 40,000,000 400 30,000,000 300 20,000,000 200 10,000,000 100 0 0 Hydrocodone Methadone Oxycodone Buprenorphine DEA Automation of Reports and Consolidated Orders System Number of Drug Poisoning Deaths: United States: CDC 1999—2013 14000 12000 10000 Other Opiates 8000 Methadone Other Synthetics 6000 Benzodiazepines Heroin 4000 2000 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Source: CDC/NCHS WONDER-National Vital Statistics System, Mortality File. Jane Maxwell, UT Addiction Research Institute, 512 232-0610
Oxycodone Indicators of oxycodone use based on items distributed by manufacturer, items identified in forensic laboratories, and deaths due to other opiates 80,000,000 250000 200000 60,000,000 150000 40,000,000 100000 20,000,000 50000 0 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Grams Distributed Tox Labs Deaths Treatment Source: NFLIS, NCHS, ARCOS, TEDS Hydrocodone (% of items identified in forensic laboratories and grams distribution by manufacturers) 50,000,000 250000 40,000,000 200000 30,000,000 150000 20,000,000 100000 10,000,000 50000 0 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Grams Distributed Tox Labs Deaths Treatment Source: NFLIS,, ARCOS Heroin (Deaths, % of Items Identified in NFLIS & Treatment Admissions) 9000 20 16 6000 12 8 3000 4 0 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Deaths Tox Labs Treatment Source: NFLIS, NCHS, TEDS Jane Maxwell, UT Addiction Research Institute, 512 232-0610
Methadone Items Identified in NFLIS, Deaths and ARCOS 10000 20,000,000 8000 16,000,000 6000 12,000,000 4000 8,000,000 2000 4,000,000 0 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Tox Labs Deaths Grams Distributed Source: NFLIS, NCHS, ARCOS Admissions to Treatment Programs by Primary Substance of Abuse: TEDS 1992-2012 100 39 80 60 % of All Admissions 60 Alcohol Other Drugs 35 Other Opiates 40 Heroin 28 9 20 1 16 11 0 1992 2012 SAMHSA Treatment Episode Dataset Changes in the Proportion of White Clients Entering Treatment: TEDS 1992-2012 100% 90% 84% 80% 70% 60% 47% 40% 20% 0% Heroin Other Opiates & Synthetics 1992 2012 15 SAMHSA Treatment Episode Dataset Jane Maxwell, UT Addiction Research Institute, 512 232-0610
Proportion of Clients Under Age 30 Entering Treatment: TEDS 1992-2012 60% 52% 50% 43% 40% 30% 26% 20% 20% 10% 0% Heroin Other Opiates & Synthetics 1992 2012 16 SAMHSA Treatment Episode Dataset Rates per 100,000 of Drug Poisoning Deaths Involving Heroin in the US: 1999-2013 7 6.3 6 5 4.4 Rate per 100,000 3.8 4 2.9 3 2.1 1.8 2 1.3 1.0 1 0.5 0.3 0 15-24 years 25-34 years 35-44 years 45-54 years 55-64 years 1999 2013 Source: CDC/NCHS WONDER-National Vital Statistics System, Mortality File Rates per 100,000 of Drug Poisoning Deaths Involving Other Opiates in the US: 1999-2013 12 10.7 10 8.7 7.6 Rate per100,000 7.5 8 6 4 2.7 2.3 2.0 2 1.3 1.4 0.7 0.5 0.3 0 15-24 years 25-34 years 35-44 years 45-54 years 55-64 years 65-74 years 1999 2013 Source: CDC/NCHS WONDER-National Vital Statistics System, Mortality File, Jane Maxwell, UT Addiction Research Institute, 512 232-0610
Estimated Number of Patients Receiving MAT: 2002-2013 Buprenorphine (Duo) Buprenorphine (Mono) Methadone NSSATS Naltrexone (Oral) (Opiate Dep) 1,200,000 1,000,000 800,000 600,000 400,000 200,000 0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Source: IMS Total Patient Tracker, Sep 2014. Buprenorphine data exclude forms indicated for pain. Oral naltrexone factored for opioid dependence use only (40% factor provided by Alkermes). Methadone patients, N-SSATS Opioid and Heroin Patients Receiving Methadone or Prescriptions for Buprenorphine or Naltrexone vs. Abuse/Dependent or Past Month Users of Pain Relievers Nonmedically or Heroin: 2012 5,197,000 1,462,069 Opioid and Heroin Patients Past Month Use of Pain Receiving MAT* Relievers or Heroin NSDUH 2012 * Number of individuals receiving buprenorphine or naltrexone from IMS plus number of patients receiving methadone from NSSATS. Source: IMS Total Patient Tracker, Sept 2014 and SAMHSA NSSATS. Buprenorphine data exclude forms indicated for pain. Oral naltrexone factored for opioid dependence use. Methadone patients from SAMHSA, N-SSATS 2012. Additional Needs • Consistent Prescription Monitoring Programs with real-time information across state lines. • Current data to determine changes in trends. • Use available data such as ARCOS and NFLIS data to pinpoint areas where prescribing practice rates do not show balance between pain relief and patient safety. • Limits on size of patient loads? • Increase the number of addiction specialists to treat patients on these new meds. • Cost of buprenorphine & naltrexone and reimbursement? Jane Maxwell, UT Addiction Research Institute, 512 232-0610
Questions for the Audience • Are today’s methadone programs easily accessible and attractive to new young suburban patients? • Do we need new treatment modalities such as detoxification to attract aging Baby Boomers addicted to pain pill and benzos? • Parallel prescribing of naloxone and pain pills for selected patients are non-compliant, on high daily doses, have been switched to another opioid, have COPD, sleep apnea, depression, or unable cognitively to manage their meds. Education for family on signs of overdose and use of naloxone. • Lack of knowledge about new MATS and targets for use + stigma of and by users Jane C. Maxwell, Ph.D. Senior Research Scientist Addiction Research Institute Center for Social Work Research The University of Texas at Austin 1717 West 6th, Suite 335 Austin, Texas 78703 512 232-0610 23 Jane Maxwell, UT Addiction Research Institute, 512 232-0610
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