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SENTINEL For PREVENTION
• Emerging Trends
• Community Surveillance
Jim Hall
Center for Applied Research on
Substance Use and Health Disparities
Nova Southeastern University
Flakka Frenzy
Novel Psychoactive
Substances (NPS)
Emerging
Synthetic Drugs
More Than Just Flakka
DRUGS
• Not “spice,” “bath salts,” nor “incense”
• Psychoactive Substances
• Change the Brain’s Functions
• Complex Chemistry
• Complicated Neuropharmacology
• The Menu:
Classes of
Novel Psychoactive Substances (NPS)
• Phenethylamines – includes Methamphetamine
• Cathinones – Stimulants & Hallucinogens
• Cannabinoids
• Tryptamines
• Piperazines
• Opiates
• Benzodiazepine Analogs
12 Kinds of Synthetic Cathinones
In Florida Crime Labs in 2014
• Cathinones – Synthetic Khat
• MDPV
• Methylone
• Alpha-PVP
• Ethylone
• Butylone
• 7 Others
The World Tour
Europe
Australia
New
Zealand
Tracking in Florida
• Crime Lab Analysis
• Medical Examiner Toxicology Testing
• Confirmed Chemical Content
184 Emerging Synthetic Drug Deaths
in Florida – 2 x 1st Half of 2014
# of Drug Occurrences
160
144
140
106
Present
120
100
Cause of Death
80
60
36
40
20
0
4
38
Cannabinoids
Cathinones
28
8
2 2
Other Synthetics
Source: FDLE – Florida Medical Examiners Commission, November 2014
35,090 Emerging Synthetic Drug
Crime Lab Reports in Florida: 2010-2014
Number of Crime Lab Reports
12000
10000
8000
Synthetic Cathinones
Synthetic Cannabinoids
Other Phenethylamines*
6000
*Other Phenethylamines 6,430
than Cathinones
1417
4000
4,338
391
301
2000
9.823
3,951
9
3922
20
3646
3441
2087
10,367
3459
1996
1290
3723
4295
4912
0
2010
2011
2012
2013
2014
Source: Analysis of US DEA - National Forensic Laboratory System Data
The Changing Face of Ecstasy, Molly, Flakka, et al
in Florida Crime Lab Reports 2010-2014
Number of Crime Lab Reports
4000
3500
3000
2500
2000
Ethylone
Methylone Cathinones
Alpha-PVP
MDPV
MDMA (Phenethylamine)
1500
1000
500
0
Ethylone
Methylone
Alpha-PVP
MDPV
MDMA
2010
0
1
0
14
1352
2011
1
141
1
163
802
2012
6
842
85
241
280
2013
4
3142
54
101
151
2014
1396
1110
672
58
150
Source: Analysis of US DEA - National Forensic Laboratory System Data
Looking for Molly
She Makes Me Want to Dance
Molly
Methylone is
beta-ketone MDMA
Ethylone Candy
Source: Metro-Dade
Police Department
Crime Lab
Ethylone Candy
Source: Metro-Dade Police Department Crime Lab
“Flakka”
• Flaca – Skinny
• Flaka – Beautiful,
elegant woman
who charms all
• Elsewhere called
“Gravel”
alpha-PVP
a-pyrrolidinopentiophenone
a-pyrrolidinovalerophenone
South Florida
Crime a-PVP Lab
Cases:
• 2012 2
• 2013 6
• 2014 - 576
Toxic
Effects:
• Tachycardia,
• Agitation,
• Psychosis,
• Violent behavior,
• Excited Delirium
• Hyperthermia
• Kidney failure
• Death
Drug Testing for Flakka
• NMS Labs -
www.nmslabs.com
• Integral Lab Solutions
www.integralabsolutions.com
(561) 935-3035
• Local Medical Examiner
Click on:
Initiatives
Facing Flakka
22 Kinds of Synthetic Cannabinoids
In Florida Crime Labs in 2014
• JWH Series – (John W. Huffman) 8 types in Florida
• AM 2201
• UR-144
• XLR-11
• PB-22
• AB-FUBINACA
• AB-PINACA
• And 8 Others in Florida
Pharmacology of Synthetic Cannabinoids
• Effects almost immediate
• Onset of action is seconds to minutes
• Duration of effects: last 30 minutes – 1 hour
• Tolerance and Dependency develops
• More drug needed for same effect
• Full and potent agonists at CB1 Receptors
• Greater receptor affinity than THC (3 - 10 Xs)
• As compared to THC, synthetic cannabinoids
produce much more intense responses with
smaller amounts of the drug
Quest
Diagnostics
www.questdiagnostics.com
Number of Crime Lab Reports
Synthetic Cannabinoids Crime Lab Cases
in Florida: 2010-2014
2200
AM-2201
2000
XLR-11
1800
AB-FUBINACA
1600
1400
1200
1000
PB-22
2013
2014
AB-PINACA
Various JWH
600
All Other Cannabinoids
400
0
1,996
1,209
UR-144
800
200
2,087
301
9
2010
2011
2012
Source: Analysis of US DEA - National Forensic Laboratory System Data
Percent of Florida High School Students
Reporting any Lifetime and Past 30-Day Use
of Synthetic Marijuana: 2012 vs.2014
15%
13%
13 % Any Lifetime
Use
11%
8.8 %
9%
Past 30-Day Use
7%
2.2 %
5%
3%
0.5%
1%
-1%
2012
2014
2012
2014
Source: Florida Youth Substance Abuse Survey 2012
785
1,301
381
140
The Future ??
• Synthetic Opiates
• Benzodiazepine-Analogs
• Etizolam
• Not Controlled in USA
• Order it on line
Dangers of Synthetic Drugs
• Excited Delirium, Kidney Failure, Death
• More Addictive and Deadly ever month
“Guinea Pig” drugs
• Both Short and Long-term Psychosis
• Linked to Violent Behavior
• Information Dissemination:
“It’s Poison and it can kill you”
Prescription Drug Abuse
in Florida
Responding to an Epidemic:
2000 to 2014
Ft. Lauderdale Pill Mill
…….The doctor is in
Florida’s Response
2009 to 2014
Florida’s Response to Rx Drug Abuse
• July 2010 – Senate Bill 2272 Legal authority to
close “Pill Mills” and limited practitioner
dispensing of CS Schedule II to 3-day supply
• August 2010 – Tamper-resistant OxyContin®.
• March 2011 – Law Enforcement Strike Force
• July 2011 - House Bill 7095 Comprehensive
law bans practitioner dispensing of CS II and
new regulations. Permits PDMP to operate.
Number of Selected Lethal Rx Opioid Occurrences
Among Deceased Persons in Florida 2008 to 2014
CS-II Dispensing Limits & OxyContin Tamper Resistant
# “Cause of Death” Occurrences
900
Strike Force
801
800
715
652
700
600
500
476 465
400
337 336
640
533
380
House Bill 7095
Takes effect
607
358
Oxycodone
392
350
274
341
300
201 176
200 153 147 160 142 139 176 144
152 136 171
100 141 129 136 129
118
110
0
340 336
Methadone
343
279 300 295
Morphine
239 268 255
219
238 221
168 170 Hydrocodone
126 158 133 119
Source: FDLE – Drugs Identified In Deceased Persons by Florida Medical Examiners
Jan 2008 - Jun 2014 Reports
Number of Hospital Cases for Non-Fatal
Rx Opioid Poisonings in Florida: 2007 -2013
Number of Rx Opioid Poisoning Patients
12000
10000
Emergency Dept
Inpatient
8,851
8,153
8000
6,754
6000
9,571
9,524
3285
3060
3160
3069
2343
6286
4000
4411
5084
6464
5691
8,442
8,626
2534
2709
5909
5917
CY 2012
CY 2013
2000
0
CY 2007
CY 2008
CY 2009
CY 2010
CY 2011
Source: Analysis of data from the Florida Agency for Health Care Administration
Rx Opioid Poisoning Hospital Cases in Florida
With and Without a Diagnosis of Opioid
Dependency: 2007-2013 n= 59,992
With
Without
54,334
91 %
9%
5,588
Source: Analysis
of data from the
Florida Agency
for Health Care
Administration
Number of Unique Patients Identified By Threshold Levels
Number of Prescribers and Number of Pharmacies
by Quarter 2012-2013
3,000
2,864
5 Prescribers &
5 Pharmacies
51-%
Decrease
Level 5
1,097
500
514
Level 7
1,415
Level 6
427
Level 8
Source: 2012-2013 Annual Report
Florida’s Prescription Drug
Monitoring Program (PDMP)
Levels 9,
10
15
178
Number of Heroin Deaths in Florida: 2000 –1st H2014
350
328
326
312
300
# Heroin Deaths
250
200
150
100
276
261
199
180
122
110
96
132
111
117
58 62
50
0
SOURCE: Florida Medical Examiners Commission Reports 2000-1st H 2014
Heroin and Morphine Deaths in Florida
2010 -2X 1st Half 2014
Number of Deaths
1000
Heroin
Morphine
Total
900
800
700
600
532
500
400
300
200
100
0
767
407
320
262
58
2010
345
568
Total
902
Morphine
590
Heroin
312
415
199
62
2011
117
2012
2013
2X 1H'14
SOURCE: Florida Medical Examiners Commission Reports 2010-2014
Heroin
from
Mexico
•
•
•
•
Increased production
Higher purity and potency
Lower Price
acetyl-fentanyl laced Heroin
Florida’s increasing heroin use should not be attributed
to the crackdown on pill mills and reductions in doctor
shopping. Without these supply-side strategies, heroin
use would have likely increased even more, because
prescription opioid abusers constitute the breeding
ground for the nation’s heroin epidemic in the 21st
Century.
However, Florida’s failure was in not expanding
treatment and prevention resources while enforcing
prescription diversion control.
Alcoholism and Drug Abuse Weekly May 4, 2015
“Budder” Beware:
Dangers of Marijuana Wax
•
•
•
•
Marijuana Wax
“Budder,” or
Butane hash oil, or even
“ear wax hash”
Produced by soaking
marijuana plant material
in a solvent such as
butane which extracts
various cannabinoids of
the plant.
DABBING
QUESTION:
What was the
Oxford English Dictionary's
2014 Word of the Year?
Answer:
The Oxford Dictionaries named "vape" 2014's
Word of the Year, the verb used to describe
inhaling and exhaling vapors produced by an
electronic cigarette or similar device.
Vape is an abbreviation of vapor or vaporize,
according to Oxford Dictionaries. Oxford
explained
“You are thirty times more likely to come across
the word vape than you were two years ago,
and usage has more than doubled in the past
year.”
The pen is mightier than the pipe?
Kratom: To Ban or Not to Ban?
Photo Source: FoxNews.com
 Large tree indigenous to Thailand and Malaysia
 Leaves are usually chewed but it can be found in a
dried form to create powder, tinctures and resins and
is sold in the US as a powder, or in capsules, and as
liquid.
Kratom Commercial Packaging
 Kratom is legal in Florida, however anything dubbed
as a “legal high” comes under suspicion and is being
watched by law enforcement.
 Kratom is not listed in the Controlled Substances Act.
The DEA added Kratom to the list of Drugs and
Chemicals of Concern.
Community Surveillance
You can’t prevent what you
don’t understand
COMMUNITY SURVEILLANCE
Problems
Partners
Planning
Prevention
Progress
COMMUNITY SURVEILLANCE
Problems
What are our local problems and
what do we know about them?
BAREFOOT EPIDEMIOLOGY
Epidemiology
• Epidemiology is the study of the
• Distribution and
• Determinants
of health-related conditions or events
(including disease and wellness), in terms of
• People,
• Place, and
• Time.
Determinant
• Determinant –
In English:
• An influencing or causal element or factor
In Florida SARG speak:
• An “Intervening Variable”
History of Epidemiology
•
•
•
•
•
•
•
1854 London (e.g., Charles Dickens)
Dr. John Snow, English Physician
Between August 31 and September 10,1854
Cholera Outbreak in Soho, London Killed 500
Conventional Wisdom: Transmitted by Air
Dr. Snow believed: Transmitted by Water
Plotted the Cholera Deaths in Soho
Broad Street
Original map
by John Snow
showing the
clusters of
cholera cases
in the Soho,
London
epidemic of
1854
Broad Street
…Action
John Smith Removed
The Broad Street Pump Handel
And the Cholera Epidemic Ended
What was Broad
Street in 1854 is
today Broadwick
Street. Shown here is
the John Snow
Memorial and the
John Snow
Memorial Pub
Substance Abuse Epidemiology
a) Consequences
b) Consumption Patterns
c) Contributing Factors
Substance Abuse Epidemiology
a)Consequences
1.
2.
3.
4.
Deaths
Medical Emergencies
Addiction
Crime
a)
b)
Violent
Property
Substance Abuse Epidemiology
b) Consumption Patterns
1. Prevalence – Proportion of Given
Population
• Use
• Frequency (Life, Annual, Past Month, Daily)
• Intensity (e.g., Bing Drinking, Heavy Use)
2. Incidence – New Cases
•
Age of First Use (% by Age 13 or Younger)
Substance Abuse Epidemiology
c) Contributing Factors
1.
2.
Risk Factors
Protective Factors
“Prevention as Protection”
COMMUNITY SURVEILLANCE
Problems – What are our local problems and what do we
know about them?
Partners
Who needs to be with us and
engaged in a mutual plan?
Applied Epi Data
Progress
Problems
Partners
Prevention
Planning
COMMUNITY SURVEILLANCE
Problems – What are our local problems and what do we
know about them?
Partners – Who needs to be with us and engaged in a
mutual plan?
Planning
What local factors can we change
that are contributing to each
problem?
SARG Needs Assessment Logic Model
Problem Statement
Determinants
1. Consequence
Data
2. Consumption
Data
SARG Needs Assessment Logic Model
Serious lifelong consequencesProblem
are linked Statement
to alcohol use by our children and youth.
Determinants
1. Consequence
Data
2. Consumption
Data
4. Problem Statement
Higher rates of
delinquency
among young
alcohol users
While use is
declining, Bing
use unchanged
1 in 4 local
youth drink by
age 13
SARG Needs Assessment Logic Model
Serious lifelong consequences are linked to alcohol use by our children and youth
Determinants
1. Consequence
Data
2. Consumption
Data
4. Problem Statement
Higher rates of
# 1 Drug Youth
delinquency
Dependency &
among
young
Juvenile
Justice
alcohol users
6. Goal
While use is
declining, Bing
use unchanged
1 in 4 local
youth drink by
age 13
Parent & Adult
Attitudes
Youth Attitudes
And Beliefs
5. Classify
Contributing Factors
as Key Determinants
Community
Norms
Early First Use
of Alcohol
7. Objectives
COMMUNITY SURVEILLANCE
Problems – What are our local problems and what do we know
about them?
Partners – Who needs to be with us and engaged in a mutual plan?
Planning – What local factors can we change that are contributing
to each problem?
Prevention
What strategies and programs will help
us change the contributing factors?
The Comprehensive Community Prevention Action Plan
• Select Strategies based on how to change identified
contributing factors (i.e., Measurable Plan Objectives)
• Who will do What Prevention Services for Whom?
• Where and When will they do it?
• Community Partners
COMMUNITY SURVEILLANCE
Problems – What are our local problems and what do we know
about them?
Partners – Who needs to be with us and engaged in a mutual
plan?
Planning – What local factors can we change that are
contributing to each problem?
Prevention – What strategies and programs will help us change
the contributing factors?
Progress
How will we measure what we have done to
change and solve the problem?
SARG Needs Assessment Logic Model
Serious lifelong consequences are linked to alcohol use by our children and youth
Determinants
1. Consequence
Data
2. Consumption
Data
4. Problem Statement
Higher rates of
delinquency
among young
alcohol users
Parent & Adult
Attitudes
5. Classify as Key
Determinants
Youth Attitudes
And Beliefs
While use is
declining, Bing
use unchanged
1 in 4 local
youth drink by
age 13
6. Goal
Community
Norms
Early First Use
of Alcohol
7. Objectives
10. Long-Term Outcomes
11. IMPACT
9. IntermediateTerm
Outcomes
8. Short -Term Outcomes
The Community Report
TABLE OF CONTENTS
• SECTION I. INTRODUCTION
• SECTION II. EMERGING DRUGS and PATTERS
of DRUG USE
• SECTION III. UPDATE on CONTINUING DRUG
USE PROBLEMS
• SECTION IV. APPENDIX with DATA TABLES
The Community Report
SECTION IV. APPENDIX with DATA TABLES
MS EXCEL WORKSHEETS AVAILABLE ONLINE AT COALITIONWEBSITE.org
• Demographic/Socio-Economic Characteristics -US Census
• Prevalence of Drug Use National Survey on Drug Use and
Health Substate (NSDUH) Data
• Prevalence of Drug Use by Age Groups NSDUH Substate
• Prevalence of Drug Use Middle & High School Students
Florida Youth Survey on Substance Abuse (FYSAS)
• 5 Year Trends in Local Treatment Admissions
• Profile of Treatment Clients by Primary Drug
The Community Report
SECTION IV. APPENDIX with DATA TABLES
MS EXCEL WORKSHEETS AVAILABLE ONLINE AT COALITIONWEBSITE.org
• CDC&P Drug Poisoning Deaths 2009-2012
• HIV/AIDS & Hepatitis Cases by Transmission Category
• National Forensic Laboratory Information System
(NFLIS) Crime Lab Cases: US DEA
• NFLIS Crime Lab Cases for Novel Psychoactive Drugs
• Drug-Related Deaths reported by Florida Medical
Examiners Commission
• Florida Poison Information Center Calls
The Community Report
TABLE OF CONTENTS
• SECTION III. UPDATE on CONTINUING DRUG
USE PROBLEMS
MAJOR SUBSTANCES WITH ONGOING but
STABLE INDICATORS OF ABUSE
• SECTION IV. APPENDIX with DATA TABLES
The Community Report
TABLE OF CONTENTS
• SECTION II. EMERGING DRUGS and
PATTERS of DRUG USE
NEW ISSUES and SUBSTANCES with
SIGNIFICANT INCREASES in INDICATORS of ABUSE
• SECTION III. UPDATE on CONTINUING DRUG USE PROBLEMS
MAJOR SUBSTANCES WITH ONGOING but
STABLE INDICATORS OF ABUSE
• SECTION IV. APPENDIX with DATA TABLES
The Community Report
TABLE OF CONTENTS
• SECTION I. INTRODUCTION
HIGHLIGHTS – BULLET POINTS
AREA DESCRIPTION
DATA SOURCES
SECTION II. EMERGING DRUGS and PATTERS of DRUG USE
NEW ISSUES and SUBSTANCES with SIGNIFICANT INCREASES in INDICATORS of ABUSE
SECTION III. UPDATE on CONTINUING DRUG USE PROBLEMS
MAJOR SUBSTANCES WITH ONGOING but STABLE INDICATORS OF ABUSE
SECTION IV. APPENDIX with DATA TABLES
Data Central
The Coalition Surveillance Committee
Public Health
Criminal Justice
Community Programs
Why Here ?
The Coalition Surveillance Committee
Public Health Sector:
Treatment - Front-Line Counselor
School System - Behavioral Health
& Substance Abuse Prevention
Hospital – Emergency Department
Department of Health
Infectious Disease Outreach
Workers
Tobacco Prevention
Medical Examiner
Pharmacist
Admissions Data
Toxicologist
FYSAS Guru
Poison Information Center
Health Education Coordinator
Managing Entity: Treatment data
The Coalition Surveillance Committee
•
Criminal Justice Sector
Law Enforcement
Local Narcotics Officer
Local Crime Lab/s
FDLE
DEA Regional Office (NFLIS and ARCOS)
Alcohol Beverage and Tobacco
Department of Juvenile Justice Intake Counselor
Courts – Drug Court
The Coalition Surveillance Committee
Community Programs
Prevention Programs
MADD
SADD
Youth Input
Social Media Monitor
COMMUNITY SURVEILLANCE
Problems
Partners
Planning
Prevention
Progress