1. Synthetic Cannabinoid Epidemiology among Florida High School Youth Hal Johnson, MPH Florida Dept. of Children & Families Substance Abuse and Mental Health Program June 10, 2013 Council of State and Territorial Epidemiologists Pasadena, California

2. Background What are synthetic cannabinoids (SC)? What are synthetic cannabinoids (SC)? –… psychoactive substances chemically similar to the active ingredient in marijuana that are applied to plant material and smoked (CESAR FAX, Vol. 22, Issue 7). –Originally developed to study cannabinoid receptors Who is using it? Who is using it? –Teenagers and young adults (DAWN report, Dec, 2012) –Males, whites and Hispanics (Stogner & Miller, J Sub Use, early only online, 2013) –Members of the LGBT community (Stogner & Miller, J Sub Use, early only online, 2013)

3. Background Why is it popular? Why is it popular? –Marketed as “safe,” legal alternative –Relatively easy access – internet, convenience stores, head shops … –Perceived as “natural” and harmless –Not detected in standard drug tests (NIDA DrugFacts, December, 2012) –No age restrictions (DAWN Report, Dec, 2012)

4. Background What are the effects/harm What are the effects/harm –Tachycardia and hypertension (2-3 times more likely than THC) –Hallucinations (5 times more likely than THC) –Seizures –Acute kidney injury (MMWR, Feb 15, 2013) –Convulsions (Schneir & Baumbacher, 2012)

5. Background At least 41 states have banned SC At least 41 states have banned SC Synthetic Drug Abuse Prevention Act Synthetic Drug Abuse Prevention Act –Signed by president July 9, 2012 –Placed 26 substances in Schedule I 15 Cannaboids 15 Cannaboids 2 cathinone derivatives (bath salts) 2 cathinone derivatives (bath salts) 9 2C phenethylamines 9 2C phenethylamines

6. Background SDAPA introduced “cannabimimetic agents” SDAPA introduced “cannabimimetic agents” –“… any substance that is a cannabinoid receptor type 1 agonist as demonstrated by binding studies and functional assays within [five specified] structural classes.” –Helpful in scheduling future synthetic cannabinoids (NFLIS 2011 Annual Report)

7. Background DEA rule (4/12/13) places methylone in Schedule I DEA rule (4/12/13) places methylone in Schedule I New SCs are used by sellers when current SC products are banned New SCs are used by sellers when current SC products are banned

8. Background 2010 Emergency Department visits (DAWN Report, Dec, 2012) – SC versus marijuana 2010 Emergency Department visits (DAWN Report, Dec, 2012) – SC versus marijuana MEASURESYNTHETIC CANNAB. MARIJUANA Total ED visits11,406461,028 Average age2430 Percent aged 12-2975%58% Percent aged 12-1733%12% Percent male (age 12- 29) 78%66% No other substance59%31%

9. Background 2011 and 2012 Poison Control Center data 2011 and 2012 Poison Control Center data

10. Background 2011 and 2012 Crime lab data – 10 fold increase 2011 and 2012 Crime lab data – 10 fold increase –More labs with ability to identify these substances

11. On-line websites retrieved 6/5/13

20. Methods Florida Youth Substance Abuse Survey Florida Youth Substance Abuse Survey –Annual school-based survey – grades 6-12 Question added to HS version in 2011 Question added to HS version in 2011 –On how many occasions (if any) have you smoked synthetic or “fake” marijuana such as spice or K2… …in your lifetime? …in the past 30 days? 2011: N=5,732 (statewide sample) 2011: N=5,732 (statewide sample) 2012: N=33,798 (county-level sample) 2012: N=33,798 (county-level sample)

21. Results

22. 2011 versus 2012 Prevalence of SC use among Florida high school youth by grade level and year, 2011-2012 + 78% + 48%

23. Gender Differences - 2012 Prevalence of SC use among Florida high school youth by gender, 2012 + 39% + 61%

24. Race/Ethnic Differences - 2012 Prevalence of SC use among Florida high school youth by race/ ethnicity, 2012 + 207% + 141%

25. Florida Compared to National Data FYSAS compared to PATS – prevalence of various substance use among high school youth, 2012 PATS: Partnership Attitude Tracking Survey (Partnership for a Drug-Free America)

26. Florida Compared to National Data FYSAS compared to MTF - prevalence of various substance use among 10 th grade youth, 2012 MTF: Monitoring the Future (NIDA; University of Michigan)

27. Florida Compared to National Data FYSAS compared to MTF - prevalence of various substance use among 12 th grade youth, 2012 MTF: Monitoring the Future (NIDA; University of Michigan)

28. SC versus Marijuana Use Lifetime use Lifetime use –Of those that used SC 94.6% used marijuana –Of those that use Marijuana 35.8% used SC Past-30-day use Past-30-day use –Of those that used SC 85.2% used marijuana –Of those that used marijuana 23.3% used SC

29. SC versus Marijuana Use Prevalence of SC and marijuana use among Florida high school youth by gender, 2012 + 39% + 13% + 61% + 35%

30. SC versus Marijuana Use Prevalence of SC and marijuana use among Florida high school youth by race/ethnicity, 2012 + 207% + 24% + 141% + 26%

31. SC vs Marijuana Odds Ratios Age, and parental education level controlled for in all analyses. Race/ethnicity controlled for in gender analyses & gender controlled for in race/ethnicity analyses.

32. Geographic Variations

33. Flagler Highlands Hardee Polk Martin St. Lucie O k ee e c h o b e e Indian River PutnamAlachua B r a d f o r d Union C o l u m b i a Gilchrist Levy Dixie Suwannee Hamilton St. Johns Clay Duval Nassau Baker Pinellas Pasco Manatee Hillsborough Brevard Osceola Orange Seminole Collier Hendry Lee Glades De Soto Sarasota Palm Beach Lake Sumter Hernando Citrus Marion Taylor Madison J e f f e r s o n Wakulla Leon Franklin Liberty Gadsden Jackson Calhoun Gulf Bay W a s h i ngton Escambia Santa Rosa Okaloosa Walton Broward Dade Holmes Monroe Volusia Lafayette Charlotte Lifetime Synthetic Cannabinoid Use Highest Quartile (18.1%-24.4%) Second Quartile (14.5%-18.0%)

34. Flagler Highlands Hardee Polk Martin St. Lucie O k ee e c h o b e e Indian River PutnamAlachua B r a d f o r d Union C o l u m b i a Gilchrist Levy Dixie Suwannee Hamilton St. Johns Clay Duval Nassau Baker Pinellas Pasco Manatee Hillsborough Brevard Osceola Orange Seminole Collier Hendry Lee Glades De Soto Sarasota Palm Beach Lake Sumter Hernando Citrus Marion Taylor Madison J e f f e r s o n Wakulla Leon Franklin Liberty Gadsden Jackson Calhoun Gulf Bay W a s h i ngton Escambia Santa Rosa Okaloosa Walton Broward Dade Holmes Monroe Volusia Lafayette Charlotte Past-30-day Synthetic Cannabinoid Use Highest Quartile (6.8%-10.9%) Second Quartile (4.8%-6.6%)

35. Flagler Highlands Hardee Polk Martin St. Lucie O k ee e c h o b e e Indian River PutnamAlachua B r a d f o r d Union C o l u m b i a Gilchrist Levy Dixie Suwannee Hamilton St. Johns Clay Duval Nassau Baker Pinellas Pasco Manatee Hillsborough Brevard Osceola Orange Seminole Collier Hendry Lee Glades De Soto Sarasota Palm Beach Lake Sumter Hernando Citrus Marion Taylor Madison J e f f e r s o n Wakulla Leon Franklin Liberty Gadsden Jackson Calhoun Gulf Bay W a s h i ngton Escambia Santa Rosa Okaloosa Walton Broward Dade Holmes Monroe Volusia Lafayette Charlotte Population Density Lowest Quartile (10-42 PSM) 2 nd Lowest Quartile (43-140 PSM) Note: Remaining counties range from 160-1,507 PSM

36. Correlation Between Substance Use and Population Density

37. Likelihood of Use by Population Density Quartile Race/ethnicity, age, gender and parental education level controlled for

38. Summary Lifetime use of SC increases with age/grade Lifetime use of SC increases with age/grade Past-30-day use shows less increase with age/grade Past-30-day use shows less increase with age/grade Though the Florida ban on SC chemicals was implemented between the 2011 and 2012 surveys, use appears to have increased slightly among HS youth Though the Florida ban on SC chemicals was implemented between the 2011 and 2012 surveys, use appears to have increased slightly among HS youth

39. Summary Use among 9 th graders increased 78% from 2011-2012 Use among 9 th graders increased 78% from 2011-2012 Use among 11 th graders increased 48% Use among 11 th graders increased 48% Males are more likely that females to use SC Males are more likely that females to use SC NH White youth are more likely to use SC than NH Black or Hispanic youth NH White youth are more likely to use SC than NH Black or Hispanic youth The gender and race/ethnicity differences are greater for SC than for marijuana use The gender and race/ethnicity differences are greater for SC than for marijuana use

40. Summary The vast majority of SC users are also marijuana users The vast majority of SC users are also marijuana users SC use among Florida youth is comparable to youth nation wide SC use among Florida youth is comparable to youth nation wide Youth in rural counties are more likely to use SC, but not marijuana, than youth in densely populated counties Youth in rural counties are more likely to use SC, but not marijuana, than youth in densely populated counties

41. Discussion Where are youth getting SC? Where are youth getting SC? New question added to FYSAS in 2013: New question added to FYSAS in 2013: –If you have used synthetic or “fake” marijuana, where did you get it? On the internet On the internet Convenience store or gas station Convenience store or gas station Tobacco or head shop Tobacco or head shop Other Other

42. Conclusion Given the consequences of SC use as indicated by poison center calls and ED visits by this age group, it is important to develop targeted prevention programs, especially for white, male youth Given the consequences of SC use as indicated by poison center calls and ED visits by this age group, it is important to develop targeted prevention programs, especially for white, male youth

43. Hal Johnson hal@dcf.state.fl.us 850-717-4420