- Dan Ciccarone, MD, MPH
-
Professor, DFCM, UCSF
• The Bad, the Good and the Ugly:
• The news we already know
• Some good news: showing the curve is cresting…
• Ugly: heroin use and consequences are up
• Intertwined epidemics
• Central dilemma: direction of causality
PUBLICALLY AVAILABLE DATA:
• NSDUH, CDC, TEDS
• Some regional data
• Hot 2014 publications
DATA ANALYZED:
• Nationwide Inpatient Survey (NIS)
• Stratified sample of approximately 20% of US community hospitals
representing 5 to 8 million hospital admissions annually?
• States included in the NIS represent about 95% of the US population
• All payer data (Medicaid, Medicare, Private Insurance and uninsured)
• Years 1993 to 2012
• Epidemic
• Morphine & heroin 18801900’s
• Heroin (wave 2, illicit,
1920 ‘s)
• Heroin (Jazz era)
• Heroin (Vietnam era)
• Heroin (Colombiansourced, 1990’s)
• Opioid pills (2000’s)
• Heroin (?)
• Trigger
• Novel drug/ Iatrogenic/
technological
• Harrison Act (restriction)?
> illicit
• Cultural?
• New source & cultural
• New Source
• Novel form (Oxy)/
technological/Iatrogenic
• New source? Restriction?
• 1999–2011
• Opioid: quadrupled
Source: Chen LH, Hedegaard H, Warner M. NCHS Data Brief, September 2014. Drug-poisoning Deaths Involving
Opioid Analgesics: United States, 1999–2011.
• Five-fold increase for
non-Hispanic Whites
Source: Chen LH, Hedegaard H, Warner M. NCHS Data Brief, September 2014. Drug-poisoning Deaths Involving
Opioid Analgesics: United States, 1999–2011.
• Six-fold increase for
55-64 y.o.
• Four-fold increase for
25-34 y.o.
Source: Chen LH, Hedegaard H, Warner M. NCHS Data Brief, September 2014. Drug-poisoning Deaths Involving
Opioid Analgesics: United States, 1999–2011.
16
14
12
10
8
• Age-adjusted death
rates per 100,000
pop.
6
4
Motor Vehicle Traffic
Drug Poisoning
2
0
Produced by: National Center for Injury Prevention and Control, CDC
Data Source: NCHS Vital Statistics System for numbers of deaths. Bureau of Census for population estimates.
Accessed: 11.5.14
16
14
Rate per 100,000
12
10
Seven fold increase
from 1993-2009
8
6
4
2
0
• NSDUH: Levelling off of opioid misuse among youth
• 12 and older: nonmedical users of OxyContin® declined from 566,000 in
2010 to 358,000 in 2012
• TEDS: Levelling off 2011-2012?:
• 194,583 (10.1%) >169,868 (9.7%)
• NIS: _________________
Past Year Nonmedical
Pain Reliever Use
among Youths and
Young Adults in NSDUH
and MTF: 2002-2012
Source: Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and
Quality. (September 4, 2014). The NSDUH Report: Substance Use and Mental Health Estimates from the 2013 National
Survey on Drug Use and Health: Overview of Findings. Rockville, MD.
Apogee reached?
Unfortunately:
• Heroin use is up
• Rise is concurrent with
the later stages of the
opioid misuse epidemic
Significant increases in
number of past month
and past year users
Source: Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and
Quality. (September 4, 2014). The NSDUH Report: Substance Use and Mental Health Estimates from the 2013 National
Survey on Drug Use and Health: Overview of Findings. Rockville, MD.
• 2000-09: 18 to 24year-olds admitted to
treatment for heroin
increased from 42,637
to 67,059 [cited in A]
• Rise in proportion of
heroin admissions by
Whites 12 and older
A. Banta-Green, CJ 2012 Adolescent Abuse of Pharmaceutical Opioids Raises Questions About
Prescribing and Prevention. Arch Pediatr Adolesc Med. 2012 May 7. [Epub ahead of print]
Sharp rise beginning
2007
6
5
Sharp increases in rates
for 20-35 y.o.
Rate Per 100,000
4
16-19
20-23
24-27
28-31
32-35
36-39
40-43
44-47
48-51
52-55
3
2
1
0
1993
1997
2001
2005
2009
Rise in Skin and Soft
Tissue Infections
• Epidemiologists in 15/21 US cities report increases in heroin,
notably among young adults and outside of urban areas (NIDA
CEWG June 2012)
• Close-up view:
• Kentucky
• Seattle WA
Heroin OD passes
Opioid OD in 2012
Drug Overdose Deaths, Hospitalizations and Emergency Department Visits in Kentucky, 2000‐2012. Prepared by
Slavova S, Bunn T, Lambert JW. Released by Kentucky Injury Prevention and Research Center (KIPRC) January, 2014
Source: PHSKC Medical Examiner’s Office
Data analysis and slide from Caleb Banta-Green, Alcohol & Drug Abuse Institute, UW
• Intertwined Epidemics
• Ethnographic data
• 2014 papers
Relationship of
Opioid ODs to
Heroin ODs
Source: Unick GJ, Rosenblum D, Mars S, Ciccarone D. Intertwined epidemics: national demographic trends in
hospitalizations for heroin- and opioid-related overdoses, 1993-2009. PLoS One. 2013
• Generational/Era effect:
• The young heroin users interviewed reported starting heroin
use after becoming dependent on opioid pills
• Some post-pill users had received prescriptions at first, while
others obtained diverted oxycodone (Percocet and Oxycontin)
• Low-cost heroin eases the transition:
• Heroin was cheaper (per equal “dose”) and more reliable in
supply
• OxyContin ‘OC’ reformulation into a non-crushable,
non-injectable gel form ‘OP’ led some users to switch to
heroin
Source: Mars S, Bourgois P, Karandinos G, Montero F, Ciccarone D. "Every 'Never' I Ever Said Came True": Transitions
from opioid pills to heroin injecting. Int J Drug Policy. 2014 Epub 2013 Oct 19.
21 year old male using heroin approx 2 years:
I mean at the time you know obviously you know when you’re
snorting Perc 30’s you’re saying to yourself I’ll never go do
Oxycontin and then you start doing Oxycontin and like I’ll never go
do dope and then you’re snorting dope, well I’ll never shoot it.
…Like look at me, I’m like a white kid from [Philadephia suburb];
it’s a nice middle-class neighborhood. I’m spending two hours on
SEPTA to come to the worst fucking place in the city – you know
what I mean to fucking sit by train tracks.
Q:
You didn’t expect to wind up here?
A:
No, God no, nobody does.
… like a lot of people, you start on the pills, and then the
doctor gives you some and some more, and then you get cut
off by the doctor… [so] every morning we would go to the
[dealer’s house] and they had both things, but …they never
were out of heroin…[but] three times a week…they didn’t
have the pills. So I’d have to scramble around, and then I
finally had enough and said, fuck. The hell with this, give me
a bag, and was off to the races.
- 51 year old using heroin 5-6 years,
originally prescribed Percocet for knee injury
75% of the 2000
cohort of heroin tx pts
started with an
prescription opioid
Cicero TJ, Ellis MS; Surratt HL; Kurtz SP. The Changing Face of Heroin Use in the United States: A Retrospective
Analysis of the Past 50 Years. JAMA Psychiatry. Published online May 28, 2014.
• US
• Health category
• Jan. 2006 to Nov.
2014
Data Source: Google Trends (www.google.com/trends)
Search: D Ciccarone, 11.3.14
Analysis: J Unick
FIGURE 1. Absolute change in heroin overdose death rates*
compared with change in prescription opioid pain reliever (OPR)
overdose death rates — 18 states, 2010 to 2012†
• Heroin deaths rising in all
18 states
• No overall correlation
bet. declining opioid rates
and rising heroin rates
•
Absolute rate change, heroin
4.0
3.0
2.0
1.0
0.0
-1.0
-2.0
But…
MMWR / October 3, 2014 / Vol. 63 / No. 39
• Pendulum swinging on pain and pain relief
• “Opioid refugees”
• Dual stewardship: “Gatekeeper” vs “therapeutic” roles
• “The present generation has been so thoroughly warned, both by teaching at
college and by observation, that now they are in many instances so very
afraid to give it, even for the worse pain, that the patient suffers agonies
worse than any hell for want of one-eighth of a grain of morphine.” - New
Hampshire physician Oscar C. Young, 1902
• “Turning off the tap”
Jay Unick, PhD, Univ of Maryland
Sarah Mars, PhD, UCSF
Philippe Bourgois, PhD, Univ of Penn
Fernando Montero, ethnographer
George Karandinos, ethnographer
Caleb Banta-Green, PhD
NIH/NIDA/NIAID funding: 1R01DA27599