The Emerging Threat of Stimulants TAKEAWAYS from the Pre-Summit Plenary Presentation by John L. Eadie, MPA 2018 National Rx Drug Abuse and Heroin Summit During the RX Summit held in Atlanta, Georgia, a pre-summit plenary presentation entitled Stimulants and Opioids: An Emerging Drug Threat in the Midst of the Opioid Epidemic was given on April 2, 2018 by John L. Eadie, MPA, Coordinator, Public Health and Prescription Drug Monitoring Program Project; National Emerging Threat Initiative; A National HIDTA Initiative Member; and National Rx Drug Abuse & Heroin Summit Advisory Board. This slide set represents 10 Takeaways from that plenary session. For the purpose of the presentation, Illicit Stimulant Drug Use was defined as the illicit use of cocaine and methamphetamine, and non-medical use of stimulant psychotherapeutics. A link to the full presentation can be found on the final slide.

1 Kg Heroin 15.5 Kg of Stimulants According to data from the High Intensity Drug Trafficking Areas (HIDTA), 15.5 Kg of Stimulants Seized for Every 1 Kg Heroin Data from High Intensity Drug Trafficking Areas (HIDTAs) show that 15.5 Kg of stimulants are seized for every 1.0 Kg of heroin. Total seizures between 2010 and 2016 included 38,586.3 Kg of heroin, and 596,998.7 Kg of stimulants combined (469,144.6 Kg of cocaine and 127,854.1 Kg of methamphetamine).

Between 2010 and 2016, HIDTA seizures resulted in 1 Between 2010 and 2016, HIDTA seizures resulted in 1.3 pounds of illicit stimulants, compared to 85,000 pounds of heroin. HIDTA seizures between 2010 and 2016 resulted in 1.3 pounds of illicit stimulants and 85,000 pounds of heroin.

Prescriptions for Stimulants Prescriptions for stimulants are increasing Since 2013, the number of new stimulant users has surpassed the number of new opioid users. Stimulant Use Government survey data show that illicit stimulant abuse is increasing rapidly across the United States. Although prescriptions written for opioids and other controlled substances have decreased, those written for stimulants have increased. Prescriptions for Stimulants Prescriptions for Opioids and Other Controlled Substances National Survey on Drug Use and Health (NSDUH) 2010 -2016

New Initiates – Nonmedical/Illicit Users: Stimulants 2.6 million By 2016, new users of non-medical opioid use rose to 2.3 million; new initiates of non-medical and illicit stimulant use rose to 2.6 million. New Initiates – Nonmedical/Illicit Users: Opioids A surge of new initiate stimulant users began in 2013, and new initiates of non-medical use of opioids rose to 2.3 million while new initiates of non-medical and illicit stimulants rose to 2.6 million by 2016 (National Survey on Drug Use and Health (NSDUH) 2010 -2016). National Survey on Drug Use and Health (NSDUH) 2010 -2016

National Survey on Drug Use and Health (NSDUH) 2010 -2016 Reported past month use in 2016 showed that non-medical or illicit stimulant use (4.3 million) exceeded non-medical or illicit opioid use (3.8 million). NSDUH data also showed that in 2016, past month non-medical or illicit stimulant users, at 4.3 million out-numbered non-medical or illicit opioid users at 3.8 million. National Survey on Drug Use and Health (NSDUH) 2010 -2016

2012 to 2015 Rise: Cocaine & Opioid Deaths The number of deaths involving cocaine and opioids (red line) has increased since 2010. Data from the Centers for Disease Control and Prevention (CDC) Wonder Reports and the National Institute for Drug Abuse (NIDA) shows that while the number of opioid-involved cocaine deaths and the number of deaths involving just cocaine were equal in 2010, the number of cocaine-related deaths rose by 9% and the number of deaths involving both cocaine and opioids more than doubled by 2015. National Center for Health Statistics, CDC Wonder; National Institute for Drug Abuse (NIDA)

HIDTAs and Respective States 2010 to 2016 HIDTA State Appalachia KY New England MA TN New York/New Jersey NY Atlantic/Carolinas NC Northwest WA Central Valley California CA Ohio OH Los Angeles Oregon OR Northern California Texoma OK Southwest Border-San Diego Washington/Baltimore MD Gulf Coast AR The states listed here were selected as representative among 15 HIDTAs, 10 of which had increases in cocaine and/or methamphetamine seizures.

In general, opioid prescription rates peaked in each of the 15 HIDTA states from 2011 through 2015 and declined through 2016. In comparing 2010 to 2016 data for opioid and other controlled substances from states that represented 15 HIDTAs, prescription rates peaked in each state from 2011 through 2015 and all declined through 2016.

Stimulant prescription rates steadily rose between 2010 and 2016. In comparing data for stimulants, for the same representative states, all prescription rates were at the lowest level in 2010 and increased through 2016 for all states except Ohio, which increase for five years and leveled off in 2016. In comparing data for stimulants for the same representative states, all prescription rates were at the lowest level in 2010 and increased through 2016 for all states except Ohio, which increased for five years and leveled off in 2016.

Implications for ALL states include, but are not limited to: the need for training of EMS and ER staff to identify and treat stimulant overdose treatment modalities for overdose in light of Naloxone working only for opioids recognizing and treating opioid-involved stimulant overdoses prescribing guidelines for children and adults similar to those for opioids mandated prescriber review of PDMP prior to writing a prescription oversight of prescriber compliance with PDMP data review requirements possible actions states should take regarding non-compliance with PDMP review requirements These data have implications for states on a variety of issues, including but not limited to: the need for training EMS and ER staff to identify and treat stimulant overdose; treatment modalities for overdose in light of Naloxone working only for opioids; recognizing and treating opioid-involved stimulant overdoses; prescribing guidelines for children and adults similar to those for opioids; mandated prescriber review of PDMP prior to writing a prescription; oversight of prescriber compliance with PDMP data review requirements; and possible actions states should take regarding non-compliance with PDMP review requirements.

Presentation slides available at https://ncric.org/files/D2DF00000/029.pdf The full pre-plenary presentation, Stimulants and Opioids: An Emerging Drug Threat in the Midst of the Opioid Epidemic, can be viewed at https://ncric.org/files/D2DF00000/029.pdf