2. Community Epidemiology Report Fall 2014 South Florida Drug Abuse Trends Update

3. James N. Hall, Epidemiologist Center for Applied Research on Substance Use and Health Disparities Nova Southeastern University

4. 1.8 Million 1.4 Million 2.6 Million 19.5 Million US Census Bureau 2013 Population Estimates

5. South Florida Most Recent Indicator Changes Marijuana: Marijuana: Down – Grow House “Wax” Cocaine: Cocaine: Stable, Mostly Modest Declines Rx Rx Opioids: Deaths Declining Hydromorphone Benzodiazepines: Benzodiazepines: Deaths Declining Methylone Methylone as Mollys: Escalating Other Other Emerging Synthetic Drugs Heroin: Heroin: Increases related to Rx Opioids crackdown Methamphetamine: Methamphetamine: Increasing among MSM et al MDMA: MDMA: Disappearing Muscle Muscle Relaxants: Declining HIGH Moderate Lower Levels of Indicator Intensity: HIGH Moderate Lower Fall 2014

6. South Florida Key Findings 2014 # 1 Key Change: There has been significant progress in reducing RX drug diversion along with moderate declines in consequences related to the nonmedical use of pharmaceuticals in most of Florida. However the availability of Hydromorphone (e.g. Dilaudid®) and deaths related to its misuse are rapidly rising. Fall 2014 # 2 Key Change: Methylone along with other hallucinogens are the fastest rising drugs analyzed by South Florida crime labs. There were 1,194 methylone crime lab items, mostly sold as “Mollys,” compared to only 54 MDMA reports in 2013.

7. Percent of Primary Addiction Treatment Admissions by Substance 2007-2012: State of Florida Percent of All Admissions Source: Substance Abuse and Mental Health Services Administration’s Center for Behavioral Health Statistics and Quality: Treatment Episode Data Set as provided by the Florida Department of Children and Families as of May 8, 2014. Marijuana Alcohol Cocaine Rx Opioids All Other Heroin

8. Exhibit 4 Top 10 Most Frequently Identified Drugs of Total Reports from South Florida Crime Labs Reports CY 2013 1 Drug 2013 % Δ vs. 2012 Cocaine 10,147 Down 11 % Marijuana/Cannabis/THC 5,276 Down 2 % Methylone (N-Methyl-3,4- Methylenedioxycathinone) 1,194 Up 208 % Hallucinogen 984 Up 88 % Rx Opioids 933 Down 4 % Heroin 925 Up 33 % Rx Benzodiazepines 849 Down 4 % Methamphetamine 211 Up 24 % Phenylimidothiazole Isomer 154 Down 37 % Caffeine 131 Down 45 % All Other Analyzed Drugs 2,272 Down 18 % Total 23,069 Down 3 % 1 Data are for January–December 2013 and include primary, secondary, and tertiary reports. SOURCE: NFLIS, DEA, data retrieved May 9, 2014

9. Miami MSA includes Palm Beach, Broward, and Miami-Dade Counties

10. Number of Cocaine Reports Detected Among Decedents in Florida: 2000 - 2013 NUMBER of COCAINE OCCURRENCES Including “Present” & “Cause of Death” SOURCE: Florida Medical Examiners Commission Interim Report Jan-June 2013 Broward Palm Beach

11. Number of Cocaine Reports Detected Among Decedents in Florida: 2000 - 2013 NUMBER of COCAINE OCCURRENCES Including “Present” & “Cause of Death” SOURCE: Florida Medical Examiners Commission Interim Report Jan-June 2013 Miami-Dade Broward Palm Beach

12. Cocaine Trends Related Deaths20122 X 1h2013Δ 2012 vs. x1h2013 State of Florida1,3181,336Up 1 % Palm Beach County87100Up 15 % Broward County12982Down 36 % So FL Crime Labs20122013 Δ 2012 vs. 2013 3 SE FL Counties11,41110,147Down 11 % Primary Treatment20112012 Δ 2011 vs. 2012 State of Florida8.5 %8.2 %Down 4 %

13. Rx Nonmedical Use in Florida 2000 -2013 Responding to an Epidemic

14. Florida’s Response 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.

15. Lethal Number of Selected Lethal Rx Opioid Occurrences Among Deceased Persons in Florida Jan 2008 to Jun 2013 Source: FDLE – Drugs Identified In Deceased Persons by Florida Medical Examiners Jan 2008 - Jun 2013 Reports # “Cause of Death” Occurrences House Bill 7095 Takes effect CS-II Dispensing Limits & OxyContin Tamper Resistant Strike Force

16. Exhibit 6 Number of Nonmedical Rx Opioids and Benzodiazepine Reports Detected among Decedents in Florida 2005 – 2x1h2013 # of Drugs Detected Among Decedents House Bill 7095 Takes effect CS-II Dispensing Limits and OxyContin Tamper Resistant Strike Force Source: FDLE – Drugs Identified In Deceased Persons by Florida Medical Examiners Jan 2005 - Jun 2013 Reports

17. Number of Unique Patients Identified By Threshold Levels Number of Prescribers and Number of Pharmacies by Quarter 2012-2013 Level 5 Level 6 Level 7 Level 8 Levels 9, 10 15 Source: 2012-2013 Annual Report Florida’s Prescription Drug Monitoring Program (PDMP) 3,000 500 5 Prescribers & 5 Pharmacies 2,864 1,415 1,097 427 514 178 51-% Decrease

18. Grams of Oxycodone Sales in Florida Per 100,000 Population # 1 # 19 # 22 Source: US Drug Enforcement Administration – ARCOS Automation of Reports and Consolidated Orders System Grams of Oxycodone Sold per 100,000

19. Hydromorphone (eg., Dilaudid ® ) STATE TOTAL GRAMS GRAMS/ 100K POP 1FLORIDA270,718.701,439.89 2DELAWARE10,501.641,169.53 3VERMONT6,099.61974.78 4CONNECTICUT34,362.81961.44 5VIRGINIA67,026.15837.72 6MONTANA8,049.45813.56 7 NEW HAMPSHIRE10,389.74789.21 8MARYLAND43,353.71750.9 9WASHINGTON48,346.19718.95 10OREGON27,172.92709.28 # of Deaths 2013 ARCOS Grams Sold Per 100/Population Source: US DEA ARCOS 3 Report 4 March 5, 2014 Source: Florida Medical Examiners Commission South Florida Crime Lab Cases Up 950-% 2011-2013 2 X1H

20. Exhibit 4 Top 10 Most Frequently Identified Drugs of Total Reports from South Florida Crime Labs Reports CY 2013 1 Drug 2013 % Δ vs. 2012 Cocaine 10,147 Down 11 % Marijuana/Cannabis/THC 5,276 Down 2 % Methylone (N-Methyl-3,4- Methylenedioxycathinone) 1,194 Up 208 % Hallucinogen 984 Up 88 % Rx Opioids 933 Down 4 % Heroin 925 Up 33 % Rx Benzodiazepines 849 Down 4 % Methamphetamine 211 Up 24 % Phenylimidothiazole Isomer 154 Down 37 % Caffeine 131 Down 45 % All Other Analyzed Drugs 2,272 Down 18 % Total 23,069 Down 3 % 1 Data are for January–December 2013 and include primary, secondary, and tertiary reports. SOURCE: NFLIS, DEA, data retrieved May 9, 2014

22. Number of Heroin Deaths in Florida: 2000 – 2x1h2013 # Heroin Deaths SOURCE: Florida Medical Examiners Commission Reports 2000-2013

23. Number of Heroin Deaths in Florida: 2000 – 2x1h2013 # Heroin Deaths SOURCE: Florida Medical Examiners Commission Reports 2000-2013

25. Heroin Trends Related Deaths20122 x 1H 2013Δ 2012 vs. 2X1h 2013 State of Florida117140Up 20 % Palm Beach County620 Up 233 % Broward County94 Down 56 % So FL Crime Labs20122013 Δ 2012 vs. 2013 3 SE FL Counties696925Up 33 % Primary Treatment20112012 Δ 2011 vs. 2012 State of Florida2.2 %3.2 %Up 45 %

26. Top 10 Most Frequently Identified Drugs of Total Reports from South Florida Crime Labs Reports CY 2013 1 Drug 2013 % Δ vs. 2012 Cocaine 10,147 Down 11 % Marijuana/Cannabis/THC 5,276 Down 2 % Methylone (N-Methyl-3,4- Methylenedioxycathinone) 1,194 Up 208 % Hallucinogen 984 Up 88 % Rx Opioids 933 Down 4 % Heroin 925 Up 33 % Rx Benzodiazepines 849 Down 4 % Methamphetamine 211 Up 24 % Phenylimidothiazole Isomer 154 Down 37 % Caffeine 131 Down 45 % All Other Analyzed Drugs 2,272 Down 18 % Total 23,069 Down 3 % Source: US DEA – National Forensic Laboratory Information System as of May 9, 2014

27. Methylone is beta-ketone MDMA Molly

28. * The synthetic cathinones mephedrone and methylone act on the brain like MDMA * Number of Items

30. South Florida Crime Labs Reports SOURCE: US DEA: National Forensic Laboratory Information System DQS on May 9, 2014 Emerging Psychoactive Substances 2011–2013 Number of Different Drugs

31. Current (past 30-day) Marijuana Use Among Broward County Middle and High School Students 2000-2012 Source: Florida Youth Substance Abuse Surveys 2000-2012

32. Percent of Broward County High School Students Reporting Marijuana Use by Age 13 or Younger 2000-2012 Source: Florida Youth Substance Abuse Surveys 2000-2012 % Reporting Use by Age 13

33. Current (past 30-day) Marijuana Use Among Palm Beach County Middle and High School Students 2000-2012 Source: Florida Youth Substance Abuse Surveys 2000-2012

34. Percent of Palm Beach County High School Students Reporting Marijuana Use by Age 13 or Younger 2000-2012 Source: Florida Youth Substance Abuse Surveys 2000-2012 % Reporting Use by Age 13

35. Addiction is a Developmental Disease: It Starts Early 57% 1.5% 5.5% <12 12-17 18-25>25 36% First Marijuana Use, (Percent of Initiates) Source: US Dept HHS: SAMHSA National Survey on Drug Use & Health 2011 Percent of First Time Marijuana Users By Age

36. A major concern about marijuana use among youth is the link between its early first use and life-long drug dependency and addiction problems. Nearly 13 percent of adults who met the criteria for drug abuse or dependency in the past year first used marijuana by age 14 or younger as compared to 2 percent of those who did not use marijuana for the first time until age 18 or older. (Source: US Department of HHS: SAMHSA 2011 National Survey on Drug Use and Health, Released August 2012.)

37. Percent of Past Year Drug Dependence or Abuse Among Adults Aged 18 or Older By Age of First Marijuana Use: 2011 Source: SAMHSA-National Surveys on Drug Use and Health 2011 14 yrs. Or Younger 18 or Older

38. Percent of Past Year Serious Mental Illness Among Lifetime Marijuana Users Aged 18 or Older By Age of First Marijuana Use: 2002 and 2003 Source: SAMHSA-National Surveys on Drug Use and Health 2002-2003 < 12 yrs. 12-14 yrs. 15-17 yrs. 18 or Older

39. Percent of high school students having ridden or driven in the past 30 days with or as driver having used marijuana or alcohol RODE with Driver who had used marijuana or alcohol DROVE after using marijuana or drinking alcohol % Reporting Source: FL-DCF - 2012 Florida Youth Substance Abuse Survey

40. Percent of High School Males Reporting Having Used Synthetic Marijuana Florida and Broward County - 2012 Source: Florida Youth Substance Abuse Survey 2012

41. Percent of High School Males Reporting Having Used Synthetic Marijuana Florida and Palm Beach County - 2012 Source: Florida Youth Substance Abuse Survey 2012

42. Number of Synthetic Cannabinoids Poison Control Exposure Calls 2012 2013 Jan-Apr 2014 Source: Florida Poison Information Center – Miami 1-800-222-1222 Synthetic Cannabinoids Poison Exposure Calls # of Poison Exposure Calls Jan-Dec 2012 # of Poison Exposure Calls Jan-Dec 2013 # of Poison Exposure Calls Jan-Apr 2014 State of Florida 537*194**34 Broward County 3770 Miami-Dade County 4593 Palm Beach County 2460 * The total of 537 includes 271 calls in January-April 2012 ** The total of 194 includes 78 calls in January-April 2013

44. 29.2

45. Marijuana Trends So FL Crime Labs20122013 Δ 2012 vs. 2013 3 SE FL Counties5,3885,276Down 2 % Detected in ME Decedents 20122 x 1H 2013Δ 2012 vs. 2X1h 2013 State of Florida767802Up 5 % Primary Treatment20112012 Δ 2011 vs. 2012 State of Florida25.1 %23 %Down 8 %

46. “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.

47. Thirty-four percent or 1/3 of High School Seniors who say that they have used marijuana in the past year who live in the states that have passed medical marijuana laws report that one of their sources of marijuana is another person's medical marijuana prescription. And 6 percent say they get it from their own prescription. It thus appears that state medical marijuana laws provide an additional avenue of accessibility to the drug for teens. (Source: US Department of HHS: NIH-NIDA 2013 Monitoring the Future Survey Released December 2013)

51. The Question for Doctors……..

52. How a Bill becomes Law How a Pill becomes Medicine US Food and Drug Administration Clinical Trials FDA Medical Review FDA Medical Panel Approval

53. Marijuana Use in the Past Month Age 12 and Above: Comparison of 2004-06, 2006-08, 2008-10 & 2010-12 NSDUH: Metro Denver vs. Colorado vs. USA

54. Perception of Great Risk of Smoking Marijuana Once a Month: Comparison of 2004-2006, 2006-2008, 2008-2010, & 2010-2012 NSDUH: Denver Metro vs. Colorado vs. USA Source: National Survey on Drug Use and Health Substate Data

56. Current (past 30-day) Alcohol Use Among Palm Beach County Middle and High School Students 2000-2012 Source: Florida Youth Substance Abuse Surveys 2000-2012

57. Current (past 30-day) Binge Drinking Among Palm Beach County Middle & High School Students 2000-20012 Source: Florida Youth Substance Abuse Surveys 2000-2012

58. Current Alcohol Use Among Palm Beach High County School Students by Gender 2006-2012 Source: Florida Dept. of Children & Families Florida Youth Substance Abuse Surveys 2006-2012 Note: Rates by Gender not available for 2002 to 2004

59. Percent of Palm Beach County High School Students Reporting Alcohol Use by Age 13 or Younger 2000-2012 Source: Florida Youth Substance Abuse Surveys 2000-2012 % Reporting Use by Age 13

62. Methamphetamine Arrests Broward County, FL: Jan 2010–July 2014 n=168

63. Methamphetamine Trends So FL Crime Labs20122013 Δ 2012 vs. 2013 3 SE FL Counties170211Up 24 % Related Deaths20122 x 1H 2013Δ 2012 vs. 2X1h 2013 State of Florida146162Up 11 % Primary Treatment20112012 Δ 2011 vs. 2012 State of Florida1.6 %2 %Up 25 %

64. Percent of Addiction Treatment Clients Reporting Injecting Drug Use by Primary Drug at Admission: State of Florida 2012 Sources: US SAMHSA Treatment Episode Data Sets (TEDS) for Statewide 2012 Treatment Primary Drug State of Florida % Heroin 82 % Prescription Opioid 36 % Methamphetamine 27 % Cocaine 5 %

65. SBIRT Screening Brief Intervention Referral to Treatment

66. What is SBIRT? SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services For persons with substance use disorders and Those who are at risk of developing these disorders Primary care centers, trauma centers, and other community settings provide opportunities for early intervention with at- risk substance users.

67. SBIRT: Review of Key Terms Screening: Very brief set of questions that identifies risk of substance use related problems. Brief Intervention: Brief counseling that raises awareness of risks and motivates client toward acknowledgement of problem. Referral: Procedures to help patients access specialized care.

68. SBIRT Goals Increase access to care for persons with substance use disorders and those at risk of substance use disorders. Foster a continuum of care by integrating prevention, intervention, and treatment services. Improve linkages between health care services and alcohol/drug treatment services.

69. h t t p : / / b e t a. s a m h s a. g o v / s b i r t