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

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

Rx Drug Summit 2011 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 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) (OPIOID) (BENZODIAZEPINE) (OPIOID) Rx Drug Summit 2011 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

Rx Drug Summit 2011 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

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

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

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

Accidents We know the vast majority of Maine’s drug deaths are accidental overdoses, rather than suicides 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

All three northern New England states experienced a rise in the early 2000s. By 2005 the CDR had almost tripled. As in Maine, most of the deaths involve pharmaceuticals. 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

We know that the pharmaceutical deaths have impacted Maine in proportion to population density, affecting all counties. 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

Opioids = 72% of 2010 deaths The total number of deaths has remained high, and the proportion of deaths caused by pharmaceuticals has increased during the last three years. Nearly all (97%) of Maine’s drug deaths are caused by at least one pharmaceutical, usually in combination with other drugs. 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

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) Benzodiazepines are frequently found, along with other opiates and opioids and/or alcohol. 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

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

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

Before 2008 we rarely had deaths caused by pharmaceutical morphine, but when heroin deaths began to decline, deaths due to morphine pills began to increase 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

By 2009 over 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

It is important not to focus on particular drugs, as they change year to year. 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

Rx Drug Summit 2011 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

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

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

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

Rx Drug Summit 2011

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

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

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

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

Overdoses Are Just the Tip of a Very Large Societal Iceberg of Substance Abuse Deaths Crime Addiction Medical Costs Lost Productivity In sum, prescription drug overdoses are just a very tragic tip of a much larger problem that requires public health intervention. 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 SFY2004 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