1. The intranasal heroin epidemic among Latino adolescents in Texas: they're calling it "cheese." Background: Since 2005, Dallas County has experienced a sharp rise in the availability and use of intranasal heroin, commonly known on the street as “cheese.” Carlos F. Tirado 1 ; Jane C. Maxwell 2 ; Bryon H. Adinoff 1 1 University of Texas Southwestern Medical Center, Division on Addictions and NIDA Clinical Trials Network, Texas Node; 2 University of Texas at Austin, Addiction Research Institute Geographically “Confined” to Dallas County Distribution of intranasal heroin admissions by ZIP code: Concerning Trends: Demographic Characteristics (18 and under) (Dallas County admissions data 2005-08) Avg age at admission: 16.4 y/o Male:Female ratio: 1:1.2 Percent Hispanic: 91% Percent involved with juvenile justice: 49% Percent with no prior treatment: 99% Percent living with parent: 96.8% Percent with substance abusing parent in home: 22% Average grade level: 8.3 Percent IV use at time of admission: 5.2% Percent with any IV use (lifetime): 9.1% For ages 15-19, Marijuana (32%) and Cocaine (16%) were most common second drugs of choice Percent with co-morbid psychiatric problems: 24% Clinical/Behavioral Charateristics (n=25) Majority (>90%) of teens bought or were given first doses as powder Majority (>95%) of regular users were directly purchasing black tar heroin and mixing it with OTC sleep aids for personal use ~30% of regular users combined heroin with other substances such as benzodiazepines and quetiapine ~25% of regular users knew a person who overdosed or died while using IN heroin ~90% of regular users knew of some increased risk of overdose or death from combining benzodiazepines and heroin  References: 1.Marsch, LA, et al., Comparison of pharmacological treatments for opioid-dependent adolescents: a randomized control trial. Arch Gen Psychiatry, Oct. 62(10): 1157-64, 2005 2.Woody, G., Findings from a NIDA-CTN clinical trial of Bup/Nal-facilitated rehabilitation for opioid-dependent adolescents/youth adults, CPDD annual meeting, June 19 th, 2007 - Coleman, JJ, Special Report: Cheese-Heroin in Dallas, TX, Dallas Heroin Task Force, Dec 12, 2007 - Maxwell, JC, “Cheese” Heroin: The Picture Gets Clearer and the Problem More Worrisome, SAMHSA, Dec 09, 2007 Supported by: Grant# U10DA020024, Protocol CTN 0036, Clinical Trials Network (CTN) - National Institutes of Drug Abuse, NIH Office of Health Disparities Research “Cheese” is the combination of black tar heroin with OTC sleep medications containing diphenhydramine or doxylamine succinate. Average purity ranges from 2-5% heroin. Community mobilized following highly publicized overdose deaths and presentation of children as young as 9 years of age in acute heroin withdrawal Dallas County health commissioner convened a city- wide task force to organize education, prevention and treatment strategy Total by ZIP Code 130 11 1 Yearly Distribution 2005-2007 Yearly Distribution of intranasal heroin admissions by ZIP: 2005 18 9 0 2006 30 15 0 2007 70 35 0 Highest concentration of cases originating from the 75220 and 75217 ZIP codes. Cases in 75220 ZIP originating from specific high school and middle school. 7% 26% 33% 18% 30% 26% 6%8% 13% 23% 12% Heroin Deaths by Age in Dallas County: Increase in percentage of deaths in persons less than 30 y/o* ** ** Deaths recorded up to 07/01/2008 Disproportionate Impact on Hispanics: Increase in percentage of Hispanics entering treatment statewide for heroin dependence between 1989-2007 (TEDS data) 24 hrs 5-7 days 10 weeks Dallas YRBS Survey: 2005 and 2007 Relative Increase in percentage of school age Hispanics using intranasal heroin in Dallas TEDS data: 1989 to 2007 Decline in average age of admission for heroin inhalers statewide. * 97% of all heroin related deaths were found to have co-occurring substances at autopsy : 53% + Cocaine; 36% + Alcohol; 23% + Cannabis; 20% + Benzodiazepine Evidence-Based Intervention in Community Treatment Center (CTP) Findings from RCTs (Marsch, LA, et al. 1, and Woody, G, et al. 2) established feasibility and effectiveness of extended treatment with buprenorphine in an adolescent/young adult population. Rationale derived from RCTs: - An extended course of buprenorphine beyond a traditional detox time frame (4-12 weeks) may impart some level of lasting benefit - Extended, but time limited, treatments may be an alternative to long term maintenance treatments in adolescents Buprenorphine Pilot Program for Adolescent Intranasal Heroin Users Result of collaboration between managed Medicaid provider and CTP to implement evidence based medication assisted treatment (MAT) in a naturalistic setting. A “meet in the middle” approach intended to balance cost-effectiveness with quality care Primary Aims: 1.To prevent or delay relapse to IN heroin 2.To engage families in treatment process Program Schematic Transition to school, job, normative behavior Program Details - Patients stabilized for extended treatment within residential program - During brief residential stay, patient and family are introduced to MAT and prepared for IOP - 90 day supply of Bup/Nal provided by insurer at no cost - Medication is dispensed in weekly intervals, supply kept by CTP medical staff - Family group visit is yoked to weekly medication visit Preliminary results for 8 females entering pilot program since 10/2007: + Bupe “clean” UDS + Bupe, “dirty” UDS but engaged in treatment AMA Discharge, Relapse Figure Legend 34 27