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Pharmaceutical Abuse Trends in Maine

Pharmaceutical Abuse Trends in Maine. Margaret Greenwald, MD Maine Chief Medical Examiner & Marcella H. Sorg, PhD Margaret Chase Smith Policy Center University of Maine. Drug-Induced Mortality Patterns: Canary in the Coal Mine. Margaret Greenwald, MD

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Pharmaceutical Abuse Trends in Maine

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  1. Pharmaceutical Abuse Trends in Maine Margaret Greenwald, MD Maine Chief Medical Examiner & Marcella H. Sorg, PhD Margaret Chase Smith Policy Center University of Maine Rx Drug Summit 2011

  2. Drug-Induced Mortality Patterns:Canary in the Coal Mine Margaret Greenwald, MD Maine Chief Medical Examiner Rx Drug Summit 2011

  3. Perspective • Over 10 years of drug related death analysis and data collection • Increases began 1999-2000 reaching current levels around 2002 at time first published data • Early identification of now well documented nationwide epidemic of prescription drug abuse Rx Drug Summit 2011

  4. SOURCE: Maine Office of Chief Medical Examiner ANALYSIS: Rural Drug & Alcohol Research Program, Margaret Chase Smith Policy Center, University of Maine Rx Drug Summit 2011

  5. Drug Death Investigation • Determination of cause of death is complicated, time consuming, and a significant strain on the resources of the OCME • Victims often have combination of chronic diseases as well as multiple opiate and other pain relievers, antidepressants, and benzodiazepines • Police officers document scene, inventory all drugs (requires counting of all pills) and provide information about circumstances • Autopsy findings, medical history, and toxicology drug levels are compared to PMP, Drug Inventory and investigative information • Access to PMP (Prescription Monitoring Program) though extremely helpful is a recent tool Rx Drug Summit 2011

  6. (OPIOID) (OPIOID) (BENZODIAZEPINE) (OPIOID) SOURCE: MAINE OFFICE OF CHIEF MEDICAL EXAMINER ANALYSIS: RURAL DRUG & ALCOHOL RESEARCH PROGRAM, MARGARET CHASE SMITH POLICY CENTER, UNIVERSITY OF MAINE Rx Drug Summit 2011

  7. Drug Patterns Change • Since 2002, drug deaths numbers have remained relatively stable, but the involved drugs have changed. • As prescribing patterns have been modified to try to minimize abuse, the drugs involved in the deaths have reflected the most widely available opiate/ opioid • The following graph illustrates using the changing frequency of methadone and oxycodone involved in the deaths Rx Drug Summit 2011

  8. SOURCE: Maine Office of Chief Medical Examiner ANALYSIS: Rural Drug & Alcohol Research Program, Margaret Chase Smith Policy Center, University of Maine Rx Drug Summit 2011

  9. Case Example Illustrates Complexity • A young woman in her late 20s with history of chronic pain syndrome, PTSD, and ‘panic attacks’ • Prescriptions: oxycodone, fentanyl patches, alprazolam (Xanax), lexapro • Most recent prescriptions were 2 weeks prior to death for 10 fentanyl patches, 180 oxycodone, 90 alprazolam • Lived with 3 children and boyfriend • History: Boyfriend admitted that on night of death they supposedly smoked marijuana together, then she crushed and snorted her Xanax (prescribed) and some street methadone (diverted) Rx Drug Summit 2011

  10. Investigation • Autopsy: Two fentanyl patches present • Toxicology: alprazolam (prescribed), fentanyl (prescribed), clonazepam (diverted), methadone (diverted), amphetamine (diverted), and citalopram/lexapro (prescribed) • Scene Investigation: no oxycodone, empty container of alprazolam. Plate with crushed pills was accessible to children • More investigation: Father of 11 year old came to pick up son and meds. Called PD and indicated something wrong with son’s medications (Adderall) –capsules empty • PMP: early refills on alprazolam • Comment: A urine screen by prescriber might have shown absence of oxycodone, presence of methadone and possibly presence of amphetamine Rx Drug Summit 2011

  11. Observations • Drug death investigations (one small component of this epidemic) have strained resources at our office and for law enforcement • Health care practitioners are also feeling stress as they try to figure out how to adequately diagnose and treat chronic pain without having to constantly police their patients to prevent abuse . • Tools such as PMP, narcotic contracts, drug screening are all good to identify abuse, but do not prevent it. • Practitioners need community support, skills and strategies to deal with those patients who cannot or will not comply Rx Drug Summit 2011

  12. Rx Drug Summit 2011

  13. Maine Pharmaceutical Abuse: Deaths, Treatment, & Crime Marcella H. Sorg, PhD, D-ABFA Director, Rural Drug & Alcohol Research Program Rx Drug Summit 2011

  14. Accidents SOURCE: Maine Office of Chief Medical Examiner ANALYSIS: Rural Drug & Alcohol Research Program, Margaret Chase Smith Policy Center, University of Maine Rx Drug Summit 2011

  15. SOURCE: Offices of Chief Medical Examiner in Maine, New Hampshire and Vermont ANALYSIS: Rural Drug & Alcohol Research Program, Margaret Chase Smith Policy Center, University of Maine Rx Drug Summit 2011

  16. SOURCE: Maine Office of Chief Medical Examiner ANALYSIS: Rural Drug & Alcohol Research Program, Margaret Chase Smith Policy Center, University of Maine Rx Drug Summit 2011

  17. Opioids = 72% of 2010 deaths SOURCE: MAINE OFFICE OF CHIEF MEDICAL EXAMINER ANALYSIS: RURAL DRUG & ALCOHOL RESEARCH PROGRAM, MARGARET CHASE SMITH POLICY CENTER, UNIVERSITY OF MAINE Rx Drug Summit 2011

  18. Oxycodone Deaths 2010 (N=49) • 7 (oxycodone alone) • 10 (plus 1 or 2 other opioids) • 11 (plus 1 or 2 benzodiazepines) • 9 (plus 1 or 2 opioids & 1 or 2 benzodiazepines) • 2 (plus 1 or 2 benzodiazepines & alcohol) • 3 (plus 1 or 2 opioids & alcohol) • 5 (plus alcohol) • 2 (plus some other drug) SOURCE: Maine Office of Chief Medical Examiner ANALYSIS: Rural Drug & Alcohol Research Program, Margaret Chase Smith Policy Center, University of Maine Rx Drug Summit 2011

  19. DATA SOURCE: Maine Health & Environmental Testing Lab ANALYSIS: Rural Drug & Alcohol Research Program, Margaret Chase Smith Policy Center, University of Maine Rx Drug Summit 2011

  20. DATA SOURCE: Maine Health & Environmental Testing Lab ANALYSIS: Rural Drug & Alcohol Research Program, Margaret Chase Smith Policy Center, University of Maine Rx Drug Summit 2011

  21. DATA SOURCE: Maine Health & Environmental Testing Lab ANALYSIS: Rural Drug & Alcohol Research Program, Margaret Chase Smith Policy Center, University of Maine Rx Drug Summit 2011

  22. SOURCE: Maine Office of Chief Medical Examiner ANALYSIS: Rural Drug & Alcohol Research Program, Margaret Chase Smith Policy Center, University of Maine Rx Drug Summit 2011

  23. SOURCE: Maine Office of Chief Medical Examiner ANALYSIS: Rural Drug & Alcohol Research Program, Margaret Chase Smith Policy Center, University of Maine Rx Drug Summit 2011

  24. SOURCE: Maine Office of Substance Abuse, Prescription Monitoring Program ANALYSIS: Rural Drug & Alcohol Research Program, Margaret Chase Smith Policy Center, University of Maine Rx Drug Summit 2011

  25. SOURCE: Maine Office of Chief Medical Examiner ANALYSIS: Rural Drug & Alcohol Research Program, Margaret Chase Smith Policy Center, University of Maine Rx Drug Summit 2011

  26. DATA SOURCE: Maine Office of Substance Abuse ANALYSIS: Rural Drug & Alcohol Research Program, Margaret Chase Smith Policy Center, University of Maine Rx Drug Summit 2011

  27. 42% in 2011 through Sept. DATA SOURCE: Maine Drug Enforcement Agency ANALYSIS: Rural Drug & Alcohol Research Program, Margaret Chase Smith Policy Center, University of Maine Rx Drug Summit 2011

  28. DATA SOURCE: Maine Drug Enforcement Agency ANALYSIS: Rural Drug & Alcohol Research Program, Margaret Chase Smith Policy Center, University of Maine Rx Drug Summit 2011

  29. Rx Drug Summit 2011

  30. Ranked Law Enforcement Seizures Jan-May 2011 SOURCE: Health & Environmental Testing Lab ANALYSIS: Rural Drug & Alcohol Research Program, Margaret Chase Smith Policy Center, University of Maine Rx Drug Summit 2011

  31. DATA SOURCE: Maine Office of Substance Abuse ANALYSIS: RURAL DRUG & ALCOHOL RESEARCH PROGRAM, MARGARET CHASE SMITH POLICY CENTER, UNIVERSITY OF MAINE Rx Drug Summit 2011

  32. DATA SOURCE: Maine Office of Substance Abuse ANALYSIS: RURAL DRUG & ALCOHOL RESEARCH PROGRAM, MARGARET CHASE SMITH POLICY CENTER, UNIVERSITY OF MAINE Rx Drug Summit 2011

  33. DATA SOURCE: Maine Office of Substance Abuse ANALYSIS: Rural Drug & Alcohol Research Program, Margaret Chase Smith Policy Center, University of Maine Rx Drug Summit 2011

  34. Overdoses Are Just the Tip of a Very Large Societal Iceberg of Substance Abuse Deaths • Crime • Addiction • Medical Costs • Lost Productivity Rx Drug Summit 2011

  35. What We Know: Mortality • Pharmaceutical death numbers are staying high: 97% of drug deaths • Most have combination of drug types: • Opiates/opioids (74%) • Benzodiazepines (34%) • Antidepressants (35%) • Muscle relaxants (9%) • Diphenhydramine (Benadryl) (7%) • Alcohol is a co-intoxicant in 22% of drug deaths • Most opioid deaths involve oxycodone (29%), methadone (30%) morphine (10%) hydrocodone (10%), tramadol (7%), fentanyl (6%) Rx Drug Summit 2011

  36. What We Know: Arrests • Arrests for pharmaceuticals are increasing, 43% of 2010 MDEA drug arrests • Many involve a combination of drug types: (most frequent: opioids (38% in 2010) • Heroin (5%) and cocaine (22%) involvement decreased, but still important; traffickers have combination illicits & pharmaceuticals Rx Drug Summit 2011

  37. What We Know: Treatment • Treatment admissions for pharmaceuticals; primary opioid admissions were 34% of admissions • Admissions include problems at the secondary and tertiary levels involving other drugs Rx Drug Summit 2011

  38. What We Know: Supply • The supply of scheduled drugs tracked by the PMP from legitimate prescriptions has increased every year since SFY2004 • Many pharmaceuticals are unused each year and remain unsecured in households. Rx Drug Summit 2011

  39. What we don’t know • Magnitude of drug-related crimes (beyond trafficking and possession), e.g., pharmaceutical robberies, burglaries, gun trafficking • Amount of surplus in our pharmaceutical dispensing systems • Amount of illegal internet sales • Which state has the “worst” problem Rx Drug Summit 2011

  40. Summary • Maine pharmaceutical abuse is getting worse • Supplies of pharmaceuticals increasing from both legitimate and illicit sources, including unused drugs many households • Consequences are impacting public safety and public health: arrests, addiction treatment, ER visits, impaired driving, and deaths • Policy solutions need to be multi-faceted, addressing addiction risks and treatment, prescribing, drug supply, drug trafficking, and the need to monitor trends across public health and public safety arenas Rx Drug Summit 2011

  41. Thank you • This research was funded in part by: • US Dept. of Justice/Bureau of Justice Assistance • US Dept. of Justice/Offices of the United States Attorneys • National Institute on Drug Abuse/CEWG Rx Drug Summit 2011

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