1. Pharmaceutical Abuse Trends in Maine
Margaret Greenwald, MD
Maine Chief Medical Examiner
&
Marcella H. Sorg, PhD
Margaret Chase Smith Policy Center
University of Maine
Rx Drug Summit 2011

2. Drug-Induced Mortality Patterns: Canary in the Coal Mine
Margaret Greenwald, MD
Maine Chief Medical Examiner
Rx Drug Summit 2011

3. Perspective
Over 10 years of drug related death analysis and data collection
Increases began reaching current levels around 2002 at time first published data
Early identification of now well documented nationwide epidemic of prescription drug abuse
Rx Drug Summit 2011

4. Rx Drug Summit 2011 SOURCE: Maine Office of Chief Medical Examiner
ANALYSIS: Rural Drug & Alcohol Research Program, Margaret Chase Smith Policy Center, University of Maine
Rx Drug Summit 2011

5. Drug Death Investigation
Determination of cause of death is complicated, time consuming, and a significant strain on the resources of the OCME
Victims often have combination of chronic diseases as well as multiple opiate and other pain relievers, antidepressants, and benzodiazepines
Police officers document scene, inventory all drugs (requires counting of all pills) and provide information about circumstances
Autopsy findings, medical history, and toxicology drug levels are compared to PMP, Drug Inventory and investigative information
Access to PMP (Prescription Monitoring Program) though extremely helpful is a recent tool
Rx Drug Summit 2011

6. (OPIOID) (OPIOID) (BENZODIAZEPINE) (OPIOID) Rx Drug Summit 2011
SOURCE: MAINE OFFICE OF CHIEF MEDICAL EXAMINER
ANALYSIS: RURAL DRUG & ALCOHOL RESEARCH PROGRAM, MARGARET CHASE SMITH POLICY CENTER, UNIVERSITY OF MAINE
Rx Drug Summit 2011

7. Drug Patterns Change
Since 2002, drug deaths numbers have remained relatively stable, but the involved drugs have changed.
As prescribing patterns have been modified to try to minimize abuse, the drugs involved in the deaths have reflected the most widely available opiate/ opioid
The following graph illustrates using the changing frequency of methadone and oxycodone involved in the deaths
Rx Drug Summit 2011

8. Rx Drug Summit 2011 SOURCE: Maine Office of Chief Medical Examiner
ANALYSIS: Rural Drug & Alcohol Research Program, Margaret Chase Smith Policy Center, University of Maine
Rx Drug Summit 2011

9. Case Example Illustrates Complexity
A young woman in her late 20s with history of chronic pain syndrome, PTSD, and ‘panic attacks’
Prescriptions: oxycodone, fentanyl patches, alprazolam (Xanax), lexapro
Most recent prescriptions were 2 weeks prior to death for 10 fentanyl patches, 180 oxycodone, 90 alprazolam
Lived with 3 children and boyfriend
History: Boyfriend admitted that on night of death they supposedly smoked marijuana together, then she crushed and snorted her Xanax (prescribed) and some street methadone (diverted)
Rx Drug Summit 2011

10. Investigation Autopsy: Two fentanyl patches present
Toxicology: alprazolam (prescribed), fentanyl (prescribed), clonazepam (diverted), methadone (diverted), amphetamine (diverted), and citalopram/lexapro (prescribed)
Scene Investigation: no oxycodone, empty container of alprazolam. Plate with crushed pills was accessible to children
More investigation: Father of 11 year old came to pick up son and meds. Called PD and indicated something wrong with son’s medications (Adderall) –capsules empty
PMP: early refills on alprazolam
Comment: A urine screen by prescriber might have shown absence of oxycodone, presence of methadone and possibly presence of amphetamine
Rx Drug Summit 2011

11. Observations
Drug death investigations (one small component of this epidemic) have strained resources at our office and for law enforcement
Health care practitioners are also feeling stress as they try to figure out how to adequately diagnose and treat chronic pain without having to constantly police their patients to prevent abuse .
Tools such as PMP, narcotic contracts, drug screening are all good to identify abuse, but do not prevent it.
Practitioners need community support, skills and strategies to deal with those patients who cannot or will not comply
Rx Drug Summit 2011

12. Rx Drug Summit 2011

13. Maine Pharmaceutical Abuse: Deaths, Treatment, & Crime
Marcella H. Sorg, PhD, D-ABFA
Director, Rural Drug & Alcohol Research Program
Rx Drug Summit 2011

14. Accidents
We know the vast majority of Maine’s drug deaths are accidental overdoses, rather than suicides
SOURCE: Maine Office of Chief Medical Examiner
ANALYSIS: Rural Drug & Alcohol Research Program, Margaret Chase Smith Policy Center, University of Maine
Rx Drug Summit 2011

15. All three northern New England states experienced a rise in the early 2000s. By 2005 the CDR had almost tripled. As in Maine, most of the deaths involve pharmaceuticals.
SOURCE: Offices of Chief Medical Examiner in Maine, New Hampshire and Vermont
ANALYSIS: Rural Drug & Alcohol Research Program, Margaret Chase Smith Policy Center, University of Maine
Rx Drug Summit 2011

16. We know that the pharmaceutical deaths have impacted Maine in proportion to population density, affecting all counties.
SOURCE: Maine Office of Chief Medical Examiner
ANALYSIS: Rural Drug & Alcohol Research Program, Margaret Chase Smith Policy Center, University of Maine
Rx Drug Summit 2011

17. Opioids =
72% of
2010 deaths
The total number of deaths has remained high, and the proportion of deaths caused by pharmaceuticals has increased during the last three years.
Nearly all (97%) of Maine’s drug deaths are caused by at least one pharmaceutical, usually in combination with other drugs.
SOURCE: MAINE OFFICE OF CHIEF MEDICAL EXAMINER
ANALYSIS: RURAL DRUG & ALCOHOL RESEARCH PROGRAM, MARGARET CHASE SMITH POLICY CENTER, UNIVERSITY OF MAINE
Rx Drug Summit 2011

18. Oxycodone Deaths 2010 (N=49) 7 (oxycodone alone)
10 (plus 1 or 2 other opioids)
11 (plus 1 or 2 benzodiazepines)
9 (plus 1 or 2 opioids & 1 or 2 benzodiazepines)
2 (plus 1 or 2 benzodiazepines & alcohol)
3 (plus 1 or 2 opioids & alcohol)
5 (plus alcohol)
2 (plus some other drug)
Benzodiazepines are frequently found, along with other opiates and opioids and/or alcohol.
SOURCE: Maine Office of Chief Medical Examiner
ANALYSIS: Rural Drug & Alcohol Research Program, Margaret Chase Smith Policy Center, University of Maine
Rx Drug Summit 2011

19. DATA SOURCE: Maine Health & Environmental Testing Lab
ANALYSIS: Rural Drug & Alcohol Research Program, Margaret Chase Smith Policy Center, University of Maine
Rx Drug Summit 2011

20. DATA SOURCE: Maine Health & Environmental Testing Lab
ANALYSIS: Rural Drug & Alcohol Research Program, Margaret Chase Smith Policy Center, University of Maine
Rx Drug Summit 2011

21. DATA SOURCE: Maine Health & Environmental Testing Lab
ANALYSIS: Rural Drug & Alcohol Research Program, Margaret Chase Smith Policy Center, University of Maine
Rx Drug Summit 2011

22. Before 2008 we rarely had deaths caused by pharmaceutical morphine, but when heroin deaths began to decline, deaths due to morphine pills began to increase
SOURCE: Maine Office of Chief Medical Examiner
ANALYSIS: Rural Drug & Alcohol Research Program, Margaret Chase Smith Policy Center, University of Maine
Rx Drug Summit 2011

23. By 2009 over
SOURCE: Maine Office of Chief Medical Examiner
ANALYSIS: Rural Drug & Alcohol Research Program, Margaret Chase Smith Policy Center, University of Maine
Rx Drug Summit 2011

24. It is important not to focus on particular drugs, as they change year to year.
SOURCE: Maine Office of Substance Abuse, Prescription Monitoring Program
ANALYSIS: Rural Drug & Alcohol Research Program, Margaret Chase Smith Policy Center, University of Maine
Rx Drug Summit 2011

25. Rx Drug Summit 2011 SOURCE: Maine Office of Chief Medical Examiner
ANALYSIS: Rural Drug & Alcohol Research Program, Margaret Chase Smith Policy Center, University of Maine
Rx Drug Summit 2011

26. Rx Drug Summit 2011 DATA SOURCE: Maine Office of Substance Abuse
ANALYSIS: Rural Drug & Alcohol Research Program, Margaret Chase Smith Policy Center, University of Maine
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27. 42% in 2011 through Sept. Rx Drug Summit 2011
DATA SOURCE: Maine Drug Enforcement Agency
ANALYSIS: Rural Drug & Alcohol Research Program, Margaret Chase Smith Policy Center, University of Maine
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28. Rx Drug Summit 2011 DATA SOURCE: Maine Drug Enforcement Agency
ANALYSIS: Rural Drug & Alcohol Research Program, Margaret Chase Smith Policy Center, University of Maine
Rx Drug Summit 2011

29. Rx Drug Summit 2011

30. Ranked Law Enforcement Seizures Jan-May 2011
SOURCE: Health & Environmental Testing Lab
ANALYSIS: Rural Drug & Alcohol Research Program, Margaret Chase Smith Policy Center, University of Maine
Rx Drug Summit 2011

31. Rx Drug Summit 2011 DATA SOURCE: Maine Office of Substance Abuse
ANALYSIS: RURAL DRUG & ALCOHOL RESEARCH PROGRAM, MARGARET CHASE SMITH POLICY CENTER, UNIVERSITY OF MAINE
Rx Drug Summit 2011

32. Rx Drug Summit 2011 DATA SOURCE: Maine Office of Substance Abuse
ANALYSIS: RURAL DRUG & ALCOHOL RESEARCH PROGRAM, MARGARET CHASE SMITH POLICY CENTER, UNIVERSITY OF MAINE
Rx Drug Summit 2011

33. Rx Drug Summit 2011 DATA SOURCE: Maine Office of Substance Abuse
ANALYSIS: Rural Drug & Alcohol Research Program, Margaret Chase Smith Policy Center, University of Maine
Rx Drug Summit 2011

34. Overdoses Are Just the Tip of a Very Large Societal Iceberg of Substance Abuse
Deaths
Crime
Addiction
Medical Costs
Lost Productivity
In sum, prescription drug overdoses are just a very tragic tip of a much larger problem that requires public health intervention.
Rx Drug Summit 2011

35. What We Know: Mortality
Pharmaceutical death numbers are staying high: 97% of drug deaths
Most have combination of drug types:
Opiates/opioids (74%)
Benzodiazepines (34%)
Antidepressants (35%)
Muscle relaxants (9%)
Diphenhydramine (Benadryl) (7%)
Alcohol is a co-intoxicant in 22% of drug deaths
Most opioid deaths involve oxycodone (29%), methadone (30%) morphine (10%) hydrocodone (10%), tramadol (7%), fentanyl (6%)
Rx Drug Summit 2011

36. What We Know: Arrests
Arrests for pharmaceuticals are increasing, 43% of 2010 MDEA drug arrests
Many involve a combination of drug types: (most frequent: opioids (38% in 2010)
Heroin (5%) and cocaine (22%) involvement decreased, but still important; traffickers have combination illicits & pharmaceuticals
Rx Drug Summit 2011

37. What We Know: Treatment
Treatment admissions for pharmaceuticals; primary opioid admissions were 34% of admissions
Admissions include problems at the secondary and tertiary levels involving other drugs
Rx Drug Summit 2011

38. What We Know: Supply
The supply of scheduled drugs tracked by the PMP from legitimate prescriptions has increased every year since SFY2004
Many pharmaceuticals are unused each year and remain unsecured in households.
Rx Drug Summit 2011

39. What we don’t know
Magnitude of drug-related crimes (beyond trafficking and possession), e.g., pharmaceutical robberies, burglaries, gun trafficking
Amount of surplus in our pharmaceutical dispensing systems
Amount of illegal internet sales
Which state has the “worst” problem
Rx Drug Summit 2011

40. Summary Maine pharmaceutical abuse is getting worse
Supplies of pharmaceuticals increasing from both legitimate and illicit sources, including unused drugs many households
Consequences are impacting public safety and public health: arrests, addiction treatment, ER visits, impaired driving, and deaths
Policy solutions need to be multi-faceted, addressing addiction risks and treatment, prescribing, drug supply, drug trafficking, and the need to monitor trends across public health and public safety arenas
Rx Drug Summit 2011

41. Thank you This research was funded in part by:
US Dept. of Justice/Bureau of Justice Assistance
US Dept. of Justice/Offices of the United States Attorneys
National Institute on Drug Abuse/CEWG
Rx Drug Summit 2011