Sentinel for Prevention Sentinel for Prevention Workshop Sentinel for Prevention Emerging Trends Community Surveillance Jim Hall Center for Applied Research on Substance Use and Health Disparities Nova Southeastern University Jim Hall upfrontin@aol.com

Flakka Frenzy

Emerging Synthetic Drugs Novel Psychoactive Substances (NPS) Emerging Synthetic Drugs More Than Just Flakka

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

The World Tour Europe Australia New Zealand

Sentinel for Prevention Workshop Tracking in Florida Crime Lab Analysis Medical Examiner Toxicology Testing Confirmed Chemical Content Jim Hall upfrontin@aol.com

184 Emerging Synthetic Drug Deaths in Florida – 2 x 1st Half of 2014 144 25 alpha- PVP Deaths Sept. 2014 – June 15, 2015 In Broward County # of Drug Occurrences 36 Source: FDLE – Florida Medical Examiners Commission, November 2014

35,090 Emerging Synthetic Drug Crime Lab Reports in Florida: 2010-2014 10,367 9.823 *Other Phenethylamines than Cathinones 6,430 Number of Crime Lab Reports 4,338 Source: Analysis of US DEA - National Forensic Laboratory System Data

The Changing Face of Ecstasy, Molly, Flakka, et al in Florida Crime Lab Reports 2010-2014 Cathinones (Phenethylamine) Number of Crime Lab Reports Source: Analysis of US DEA - National Forensic Laboratory System Data

She Makes Me Want to Dance Looking for Molly She Makes Me Want to Dance

Molly Now Ethylone Methylone is beta-ketone MDMA

Ethylone Candy Source: Metro-Dade Police Department Crime Lab

Source: Metro-Dade Police Department Crime Lab Ethylone Candy Source: Metro-Dade Police Department Crime Lab

a-pyrrolidinovalerophenone “Flakka” Flaca – Skinny Flaka – Beautiful, elegant woman who charms all Elsewhere called “Gravel” alpha-PVP a-pyrrolidinopentiophenone a-pyrrolidinovalerophenone

Sentinel for Prevention Workshop South Florida Crime a-PVP Lab Cases: 2012 - 2 2013 - 6 2014 - 576 Toxic Effects: Tachycardia, Agitation, Psychosis, Violent behavior, Excited Delirium Hyperthermia Kidney failure Death Jim Hall upfrontin@aol.com (786) 547-7249

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 Cannabinoids In Florida Crime Labs in 2014 Sentinel for Prevention Workshop 22 Kinds of Synthetic Cannabinoids In 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 Jim Hall upfrontin@aol.com

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 2,087 1,996 1,209 Number of Crime Lab Reports 9 Source: Analysis of US DEA - National Forensic Laboratory System Data

Percent of Florida High School Students Reporting any Lifetime and Past 30-Day Use of Synthetic Marijuana: 2012 vs.2014 Past 30-Day Use Source: Florida Youth Substance Abuse Survey 2012

Sentinel for Prevention Workshop 785 1,301 381 140 Jim Hall upfrontin@aol.com

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”

Prescription Drug Abuse in Florida Responding to an Epidemic: 2000 to 2014

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.

Sentinel for Prevention Workshop Number of Selected Lethal Rx Opioid Occurrences Among Deceased Persons in Florida 2008 to 2014 CS-II Dispensing Limits & OxyContin Tamper Resistant Strike Force House Bill 7095 Takes effect # “Cause of Death” Occurrences Source: FDLE – Drugs Identified In Deceased Persons by Florida Medical Examiners Jan 2008 - Jun 2014 Reports Jim Hall upfrontin@aol.com

Number of Hospital Cases for Non-Fatal Rx Opioid Poisonings in Florida: 2007 -2013 9,571 9,524 8,851 8,626 8,442 8,153 6,754 Number of Rx Opioid Poisoning Patients Source: Analysis of data from the Florida Agency for Health Care Administration

Rx Opioid Poisoning Hospital Cases in Florida With and Without a Diagnosis of Opioid Dependency: 2007-2013 n= 59,992 9 % Source: Analysis of data from the Florida Agency for Health Care Administration 91 %

Number of Unique Patients Identified By Threshold Levels Number of Prescribers and Number of Pharmacies by Quarter 2012-2013 5 Prescribers & 5 Pharmacies 3,000 2,864 51-% Decrease Level 5 514 500 Level 7 1,097 1,415 Level 6 427 Level 8 178 Levels 9, 10 15 Source: 2012-2013 Annual Report Florida’s Prescription Drug Monitoring Program (PDMP)

Number of Heroin Deaths in Florida: 2000 –1st H2014 SOURCE: Florida Medical Examiners Commission Reports 2000-1st H 2014

Heroin and Morphine Deaths in Florida 2010 -2X 1st Half 2014 Sentinel for Prevention Workshop Heroin and Morphine Deaths in Florida 2010 -2X 1st Half 2014 Total Morphine Number of Deaths Heroin SOURCE: Florida Medical Examiners Commission Reports 2010-2014 Jim Hall upfrontin@aol.com

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

prescription diversion control. 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 enforcing prescription diversion control. Alcoholism and Drug Abuse Weekly May 4, 2015

“Budder” Beware: Dangers of 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

Kratom 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 Commercial Packaging

Legal Status of Kratom 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.

Community Surveillance You can’t prevent what you don’t understand

Community Surveillance Problems Partners Planning Prevention Progress

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

Barefoot Epidemiology

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.

Determinant Determinant – In English: An influencing or causal element or factor In Florida SARG speak: An “Intervening Variable”

History of Epidemiology Sentinel for Prevention Workshop 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 Information for Action

Broad Street Original map by John Snow showing the clusters of cholera cases in the Soho, London epidemic of 1854

Broad Street From Information to…

The Broad Street Pump Handel And the Cholera Epidemic Ended From Information to… …Action John Smith Removed The Broad Street Pump Handel And the Cholera Epidemic Ended

John Snow Memorial Pub What was Broad Street in 1854 is today Broadwick Street. Shown here is the John Snow Memorial and the John Snow Memorial Pub

Substance Abuse Epidemiology Consequences Consumption Patterns Contributing Factors

Substance Abuse Epidemiology Consequences Deaths Medical Emergencies Addiction Crime Violent Property

Substance Abuse Epidemiology b) Consumption Patterns Prevalence – Proportion of Given Population Use Frequency (Life, Annual, Past Month, Daily) Intensity (e.g., Bing Drinking, Heavy Use) Incidence – New Cases Age of First Use (% by Age 13 or Younger)

Substance Abuse Epidemiology Contributing Factors Risk Factors 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 Problems Partners Progress Prevention Planning

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 Model Problem Statement Determinants 1. Consequence Data 2. Consumption Data 3. Contributing Factors Data

SARG Needs Assessment Logic Model 1 in 4 local youth drink by age 13 Problem Statement Serious lifelong consequences are linked to alcohol use by our children and youth. Determinants 1. Consequence Data 2. Consumption Data 4. Problem Statement 3. Contributing Factors Data While use is declining, Bing use unchanged Higher rates of delinquency among young alcohol users 1 in 4 local youth drink by age 13

SARG Needs Assessment Logic Model Serious lifelong consequences are linked to alcohol use by our children and youth Determinants 1. Consequence Data 2. Consumption Data Parent & Adult Attitudes 5. Classify Contributing Factors as Key Determinants 4. Problem Statement Youth Attitudes And Beliefs 3. Contributing Factors Data While use is declining, Bing use unchanged Higher rates of delinquency among young alcohol users # 1 Drug Youth Dependency & Juvenile Justice Community Norms 1 in 4 local youth drink by age 13 6. Goal Early First Use of Alcohol 7. Objectives

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?

The Comprehensive Community Prevention Action Plan Select Strategies based on how to change identified contributing factors (i.e., Measurable Plan Objectives) 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 Model Serious lifelong consequences are linked to alcohol use by our children and youth Determinants 1. Consequence Data 2. Consumption Data Parent & Adult Attitudes 5. Classify as Key Determinants 4. Problem Statement Youth Attitudes And Beliefs 3. Contributing Factors Data While use is declining, Bing use unchanged Higher rates of delinquency among young alcohol users Community Norms 1 in 4 local youth drink by age 13 6. Goal Early First Use of Alcohol 7. Objectives 10. Long-Term Outcomes 9. Intermediate-Term Outcomes 8. Short -Term Outcomes 11. IMPACT

The Community Report TABLE 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 Report Section IV The Community Report Section 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 Report Section IV The Community Report Section 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 Report TABLE 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 Report TABLE 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 Report TABLE OF CONTENTS Section I. Introduction Highlights – Bullet Points Area Description Data Sources 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

www.drugfreebroward.org Data Central

The Coalition Surveillance Committee Public Health Criminal Justice Community Programs     Why Here ?

The Coalition Surveillance Committee Public Health Sector: Department of Health Infectious Disease Outreach Workers Tobacco Prevention Pharmacist Toxicologist  Poison Information Center Health Education Coordinator Treatment - Front-Line Counselor School System - Behavioral Health & Substance Abuse Prevention Hospital – Emergency Department Medical Examiner Admissions Data FYSAS Guru Managing Entity: Treatment data

The Coalition Surveillance Committee   Criminal Justice Sector Law Enforcement Local Narcotics Officer Local Crime Lab/s FDLE DEA Regional Office (NFLIS and ARCOS) Alcohol Beverage and Tobacco Department 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 Problems Partners Planning Prevention Progress