SENTINEL For PREVENTION Emerging Trends Community Surveillance Jim Hall Center for Applied Research on Substance Use and Health Disparities Nova Southeastern.

SENTINEL For PREVENTION

• Emerging Trends

•Community Surveillance

Jim HallCenter for Applied Research on Substance Use and Health DisparitiesNova Southeastern University

Flakka Frenzy

More Than Just Flakka

Emerging Synthetic Drugs

Novel Psychoactive Substances (NPS)

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

Europe

NewZealand

Australia

The World Tour

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

Cannabinoids Cathinones Other Synthetics0

20

40

60

80

100

120

140

160

2

38

82

106

28

Present

Cause of Death

4

144

36

# of

Dru

g O

ccur

renc

es

Source: FDLE – Florida Medical Examiners Commission, November 2014

25 alpha- PVP Deaths

Sept. 2014 – June 15, 2015

In Broward County

35,090 Emerging Synthetic Drug Crime Lab Reports in Florida: 2010-2014

2010 2011 2012 2013 20140

2000

4000

6000

8000

10000

12000

3922 3646 3723 4295 4912

9 3011290

20871996

20 391

1417

34413459

Synthetic Cathinones

Synthetic Cannabinoids

3,951 4,338

6,430

9.82310,367

Nu

mb

er

of

Cri

me L

ab

Rep

ort

s

Source: Analysis of US DEA - National Forensic Laboratory System Data

*Other Phenethylamines than Cathinones

The Changing Face of Ecstasy, Molly, Flakka, et al

in Florida Crime Lab Reports 2010-2014

2010 2011 2012 2013 2014

MDMA 1352 802 280 151 150

MDPV 14 163 241 101 58

Alpha-PVP 0 1 85 54 672

Methylone 1 141 842 3142 1110

Ethylone 0 1 6 4 1396

250

750

1250

1750

2250

2750

3250

3750EthyloneMethyloneAlpha-PVPMDPVMDMA

Nu

mb

er

of

Cri

me L

ab

Rep

ort

s

Source: Analysis of US DEA - National Forensic Laboratory System Data

(Phenethylamine)

Cathinones

She Makes Me Want to Dance

Looking for Molly

Methylone isbeta-ketone MDMA

Molly

Now

Ethylone

Ethylone Candy

Source: Metro-Dade Police Department

Crime Lab

Ethylone Candy

Source: Metro-Dade Police Department Crime Lab

a-pyrrolidinovalerophenone

“Flakka”

alpha-PVP

• Flaca – Skinny

• Flaka – Beautiful, elegant woman who charms all

• Elsewhere called “Gravel”

a-pyrrolidinopentiophenone

Toxic Effects:

• Tachycardia, • Agitation, • Psychosis, • Violent behavior, • Excited Delirium • Hyperthermia • Kidney failure • Death

South Florida Crime a-PVP Lab Cases:

• 2012 - 2• 2013 - 6 • 2014 - 576

Drug Testing for Flakka

• NMS Labs - www.nmslabs.com

• Integral Lab Solutions www.integralabsolutions.com (561) 935-3035

• Local Medical Examiner

www.drugfreebroward.

org Click on:Initiatives

Facing Flakka

22 Kinds of Synthetic CannabinoidsIn 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

Synthetic Cannabinoids Crime Lab Cases

in Florida: 2010-2014

2010 2011 2012 2013 20140

200

400

600

800

1000

1200

1400

1600

1800

2000

2200 AM-2201

XLR-11

AB-FUBINACA

PB-22

UR-144

AB-PINACA

Various JWH

All Other Cannabinoids

301

Nu

mb

er

of

Cri

me L

ab

Rep

ort

s

Source: Analysis of US DEA - National Forensic Laboratory System Data

9

1,209

2,087 1,996

Percent of Florida High School Students Reporting any Lifetime and Past 30-Day Use

of Synthetic Marijuana: 2012 vs.2014

2012 2014 2012 2014-1%

1%

3%

5%

7%

9%

11%

13%

15%13 %

8.8 %

2.2 %

0.5%

Any Lifetime Use

Source: Florida Youth Substance Abuse Survey 2012

Past 30-Day Use

140

1,301381

785

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”

Responding to an Epidemic:2000 to 2014

Prescription Drug Abuse in Florida

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

Source: FDLE – Drugs Identified In Deceased Persons by Florida Medical Examiners Jan 2008 - Jun 2014 Reports

# “C

ause

of D

eath

” O

ccur

renc

es

1H'08

2H'08

1H'09

2H'09

1H'10

2H'10

1H'11

2H'11

1H'12

2H'12

1H'13

2H'13

1H'14

0

100

200

300

400

500

600

700

800

900

476 465533

652715

801

607

640

392343

279255

219

337 336380

340 336358

341350

274

238 221168 170153 147 160 142

110152

144201 176

239 268300 295

141 129 136 129

139 176

136 171118 126 158

133 119

Oxycodone

Methadone

Morphine

Hydrocodone

House Bill 7095Takes effect

CS-II Dispensing Limits & OxyContin Tamper Resistant Strike Force

Number of Hospital Cases for Non-Fatal Rx Opioid Poisonings in Florida: 2007 -2013

Num

ber o

f Rx

Opi

oid

Pois

onin

g Pa

tient

s

Source: Analysis of data from the Florida Agency for Health Care Administration

CY 2007 CY 2008 CY 2009 CY 2010 CY 2011 CY 2012 CY 20130

2000

4000

6000

8000

10000

12000

44115084

56916286

64645909 5917

2343

30693160

3285 3060

2534 2709

Emergency DeptInpatient

6,7548,153

8,8519,571 9,524

8,442 8,626

5,588

54,334

WithWithout

Rx Opioid Poisoning Hospital Cases in Florida With and Without a Diagnosis of Opioid

Dependency: 2007-2013 n= 59,992

Source: Analysis of data from the Florida Agency for Health Care Administration91 %

9 %

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, 1015Source: 2012-2013 Annual Report

Florida’s Prescription Drug Monitoring Program (PDMP)

3,000

500

5 Prescribers &5 Pharmacies 2,864

1,4151,097

427

514

178

51-% Decrease

Number of Heroin Deaths in Florida: 2000 –1st H2014#

Her

oin

Dea

ths

SOURCE: Florida Medical Examiners Commission Reports 2000-1st H 2014

20002001

20022003

20042005

20062007

20082009

20102011

20122013

2X1H'140

50

100

150

200

250

300

350

276

328 326

261

180

122

96

110132 111

58 62

117

199

312

Heroin and Morphine Deaths in Florida2010 -2X 1st Half 2014

2010 2011 2012 2013 2X 1H'140

100

200

300

400

500

600

700

800

900

1000

5862

117199

312262 345

415

568 590

320407

532

767902

HeroinMorphineTotal

Num

ber

of D

eath

s

SOURCE: Florida Medical Examiners Commission Reports 2010-2014

Heroin

Morphine

Total

• Increased production• Higher purity and potency• Lower Price• acetyl-fentanyl laced Heroin

Heroinfrom

Mexico

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 enforcingprescription 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

Just a Little Dab

will do you….in

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

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.

Legal Status of Kratom

Community Surveillance

You can’t prevent what you don’t understand

COMMUNITY SURVEILLANCE

ProblemsPartners Planning

Prevention Progress

COMMUNITY SURVEILLANCE

Problems

What are our local problems and what do we know about them?

BAREFOOT 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.

Epidemiology

• Determinant –In English:• An influencing or causal element or factor

In Florida SARG speak:• An “Intervening Variable”

Determinant

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

Original mapby John Snow showing the clusters of cholera casesin the Soho, London epidemic of 1854

Broad Street

Broad Street

From Information to…

From Information to…

…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 theJohn Snow Memorial Pub

Substance Abuse Epidemiology

a) Consequences

b) Consumption Patterns

c) Contributing Factors

Substance Abuse Epidemiology

a)Consequences1. Deaths2. Medical Emergencies3. Addiction4. Crime

a) Violentb) Property

Substance Abuse Epidemiology

b) Consumption Patterns1. 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 Factors1. Risk Factors2. 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 ProblemsPartners

Planning

Progress

Prevention

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 ModelProblem Statement

Determinants

1. ConsequenceData

2. ConsumptionData

3. Contributing Factors

Data

SARG Needs Assessment Logic ModelProblem Statement

Determinants

1. ConsequenceData

2. ConsumptionData

3. Contributing Factors

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

Serious lifelong consequences are linked to alcohol use by our children and youth.

SARG Needs Assessment Logic ModelSerious lifelong consequences are linked to alcohol use by our children and youth

Determinants

1. ConsequenceData

2. ConsumptionData

3. Contributing Factors

Data

4. Problem Statement

7. Objectives

5. Classify Contributing Factors as Key Determinants

6. Goal

# 1 Drug Youth Dependency &Juvenile Justice

While use is declining, Bing use unchanged

1 in 4 local youth drink by

age 13

Parent & Adult Attitudes

Youth AttitudesAnd Beliefs

CommunityNorms

Early First Use of Alcohol

Higher rates of delinquency among young alcohol users

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?

• Select Strategies based on how to change identified contributing factors (i.e., Measurable Plan Objectives)

The Comprehensive Community Prevention Action Plan

• 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 ModelSerious lifelong consequences are linked to alcohol use by our children and youth

Determinants

1. ConsequenceData

2. ConsumptionData

3. Contributing Factors

Data

4. Problem Statement

11. IMPACT

7. Objectives

5. Classify as Key Determinants

9. Intermediate-Term

Outcomes

10. Long-Term Outcomes

6. Goal

8. Short -Term Outcomes

Higher rates of delinquency among young alcohol users

While use is declining, Bing use unchanged

1 in 4 local youth drink by

age 13

Parent & Adult Attitudes

Youth AttitudesAnd Beliefs

CommunityNorms

Early First Use of Alcohol

The Community ReportTABLE 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 ReportSECTION 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 ReportSECTION 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 ReportTABLE 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 ReportTABLE 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 ReportTABLE OF CONTENTS

• SECTION I. INTRODUCTIONHIGHLIGHTS – BULLET POINTSAREA DESCRIPTIONDATA SOURCES

SECTION II. EMERGING DRUGS and PATTERS of DRUG USENEW 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

www.drugfreebroward.org

Data Central

The Coalition Surveillance Committee

Public Health

Criminal Justice

Community Programs

Why Here ?

The Coalition Surveillance Committee

Treatment - Front-Line CounselorSchool System - Behavioral Health & Substance Abuse Prevention

Hospital – Emergency Department

Medical Examiner

Admissions Data

FYSAS Guru

Managing Entity: Treatment data

Department of Health Infectious Disease Outreach Workers

Tobacco Prevention

Pharmacist

Toxicologist

Poison Information Center Health Education Coordinator

Public Health Sector:

The Coalition Surveillance Committee•

Criminal Justice SectorLaw Enforcement Local Narcotics OfficerLocal Crime Lab/s

FDLEDEA Regional Office (NFLIS and ARCOS)Alcohol Beverage and TobaccoDepartment 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

ProblemsPartners Planning

Prevention Progress