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-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…

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Presentation on theme: "-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…"— Presentation transcript:

1 -Dan Ciccarone, MD, MPH -Professor, DFCM, UCSF

2 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

3 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

4 Epidemic Morphine & heroin 1880- 1900’s Heroin (wave 2, illicit, 1920 ‘s) Heroin (Jazz era) Heroin (Vietnam era) Heroin (Colombian- sourced, 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?

5 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.

6 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.

7 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.

8 Age-adjusted death rates per 100,000 pop. 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

9 Seven fold increase from 1993-2009

10 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: _________________

11 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.

12 Apogee reached?

13 Unfortunately: Heroin use is up Rise is concurrent with the later stages of the opioid misuse epidemic

14 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.

15 2000-09: 18 to 24- year-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]

16 Sharp rise beginning 2007

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18 Sharp increases in rates for 20-35 y.o.

19 Rise in Skin and Soft Tissue Infections

20

21 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

22 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

23 Source: PHSKC Medical Examiner’s Office Data analysis and slide from Caleb Banta-Green, Alcohol & Drug Abuse Institute, UW

24 Intertwined Epidemics Ethnographic data 2014 papers

25 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

26 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.

27 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.

28 … 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

29 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.

30 US Health category Jan. 2006 to Nov. 2014 Data Source: Google Trends (www.google.com/trends)www.google.com/trends Search: D Ciccarone, 11.3.14 Analysis: J Unick

31 Heroin deaths rising in all 18 states No overall correlation bet. declining opioid rates and rising heroin rates But… 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 † -2.0 0.0 1.0 2.0 3.0 4.0 Ab so lu te rate c h a ng e, h ero i n MMWR / October 3, 2014 / Vol. 63 / No. 39

32 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”

33 IJay Unick, PhD, Univ of Maryland ISarah Mars, PhD, UCSF IPhilippe Bourgois, PhD, Univ of Penn IFernando Montero, ethnographer IGeorge Karandinos, ethnographer ICaleb Banta-Green, PhD INIH/NIDA/NIAID funding: 1R01DA27599


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