Pharmaceutical Abuse Trends in Maine Margaret Greenwald MD

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

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

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

Number of Maine Deaths due to Pharmaceutical or Illicit Drugs Alone or in Combination 200 180 160 140 120 100 80 60 40 20 0 All Pharmaceutical Illicit 1997 34 30 8 1998 54 47 18 1999 66 60 13 2000 60 51 15 2001 90 74 31 2002 165 149 35 2003 153 129 47 2004 162 141 50 2005 176 139 61 2006 167 134 59 2007 154 136 49 2008 164 155 30 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 2009 179 164 22 2010 167 162 17

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

(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

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

Number of Maine Deaths Caused by Oxycodone and Methadone, Alone or in Combination with Other Drugs 60 50 40 30 20 10 0 1997 Oxycodone 0 Methadone 12 1998 6 11 1999 12 17 2000 6 38 2001 11 22 2002 28 40 2003 29 35 2004 15 46 2005 17 40 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 2006 24 41 2007 38 38 2008 27 34 2009 50 26 2010 48 30

Case Example Illustrates Complexity • A young woman in her late 20 s 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

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

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

Rx Drug Summit 2011

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

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

Northern New England States --Drug Death Rate per 100, 000 16 14 12 10 8 6 4 2 0 2001 2002 2003 2004 2005 2006 ME NH VT 2007 2008 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 2009 2010

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

Number of Maine Deaths due to Pharmaceutical or Illicit Drugs Alone or in Combination 200 180 160 140 120 Opioids = 72% of 2010 deaths 100 80 60 40 20 0 All Pharmaceutical Illicit 1997 34 30 8 1998 54 47 18 1999 66 60 13 2000 60 51 15 2001 90 74 31 2002 165 149 35 2003 153 129 47 2004 162 141 50 2005 176 139 61 2006 167 134 59 2007 154 136 49 2008 164 155 30 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 2009 179 164 22 2010 167 162 17

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

Percent of Impaired Driver Urinalyses, 2011 (n=112) BZD + OPIOID BZD OPIOID Series 1 0% OPIOID 10% 62% 20% BZD 30% 44% 40% 50%BZD + OPIOID 60% 40% 70% 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

Impaired Driver Urinalyses Percent with Key Opioids Buprenorphine 2% 7% 6% 13% Oxycodone 13% 9% 11% Hydrocodone 7% 18% 22% 30% 2011 thru May 2010 2009 2006 -8 18% 21% 19% 22% 18% Methadone 0% 10% 20% 30% 40% 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

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

Number and Percent of Heroin/Morphine-Induced Deaths (Known Pharmaceutical Morphine Deaths Removed) 50 45 40 35 30 25 20 15 10 5 0 Percent Number 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 15 5 22 12 14 9 18 11 29 26 18 29 24 36 15 24 24 43 19 32 16 25 12 20 7 13 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 2010 est 4 7

OCME: Heroin/Morphine Deaths 2009 Heroin/Morphine 26% Morphine pills 57% Heroin 17% 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

PMP: Trends in Prescriptions for Long-Acting Pharmaceutical Narcotic Analgesics 50 000 45 000 40 000 Morphine CR or ER products 35 000 MS Contin CR products 30 000 Kadian CR products 25 000 Avinza CR products 20 000 15 000 Methadone/Methadose 40 mg 10 000 Methadone/Methadose 5, 10 mg 5 000 0 2006 2007 2008 2009 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

Number & Percent of Benzodiazepine-Induced Deaths 60 50 40 30 20 10 0 Number Percent 2000 8 12 2001 12 13 2002 31 19 2003 27 18 2004 35 22 2005 35 20 2006 36 22 2007 36 23 2008 39 24 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 2009 56 31 2010 57 34

Number of Benzodiazepine Admissions 800 700 600 500 400 300 200 100 0 2000 Tertiary 115 Secondary 122 Primary 51 2001 86 132 78 2002 133 149 67 2003 205 237 88 2004 272 290 95 2005 242 236 58 2006 287 257 59 2007 300 354 91 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 2008 330 322 76 2009 356 305 86 2010 289 319 74

Rx Rx Stimulants MDEA Arrests 2010 Tranquilizers 3% 2% Cocaine/Crack 22% Rx Narcotics 38% in 2010 42% in 2011 through Sept. Heroin/Morphine 6% Marijuana 23% Methamphetamine 4% MDMA 3% DATA SOURCE: Maine Drug Enforcement Agency ANALYSIS: RURAL DRUG & ALCOHOL RESEARCH PROGRAM, MARGARET CHASE SMITH POLICY CENTER, UNIVERSITY OF MAINE Rx Drug Summit 2011

Percent of MDEA Pharmaceutical Arrests 60% 50% 40% 30% 20% 10% 0% Pharm-Narcotics Pharm-Stimulants Pharm-Tranquilizers Pharmaceutical Total 2006 2007 2008 2009 2010 23% 1% 0% 24% 21% 0% 3% 24% 34% 2% 1% 37% 39% 1% 2% 42% 38% 3% 2% 42% 2011 thru Apr 44% 1% 3% 48% DATA SOURCE: Maine Drug Enforcement Agency ANALYSIS: RURAL DRUG & ALCOHOL RESEARCH PROGRAM, MARGARET CHASE SMITH POLICY CENTER, UNIVERSITY OF MAINE Rx Drug Summit 2011

Number of Pharmacy Robberies in Maine 25 20 15 10 5 0 # Robberies 2008 2 2009 8 Rx Drug Summit 2011 2010 23 2011 est 21

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 MAIN Rx Drug Summit 2011

Percent Primary Admissions for Heroin/Morphine and Prescription Opioids (including 43% alcohol in 2010) 35% 30% 25% 20% 15% 10% 5% 0% 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Heroin/ Morphine 4% 6% 8% 7% 8% 8% 8% 7% 8% 9% 7% Opioids 6% 9% 10% 11% 13% 15% 19% 22% 27% 29% 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

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

Percent Admissions: Oxycodone vs Other Opioids 35% 30% 9% 25% 7% 20% 6% 5% 15% 3% 4% 21% 10% 5% 7% 11% 12% 2004 2005 23% 25% 16% 14% 0% 2006 2007 Oxycodone 2008 2009 Other Opioids 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 2010

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

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

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

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

What We Know: Supply • The supply of scheduled drugs tracked by the PMP from legitimate prescriptions has increased every year since SFY 2004 • Many pharmaceuticals are unused each year and remain unsecured in households. Rx Drug Summit 2011

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

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

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