Vision Session: Ameritox/Prium - Gateway To Heroin: Opioids

1. A Law Enforcement View of
Increasing Abuse of Heroin
Current Levels of Prescription Abuse
Indicate Possible Increased Abuse of
Heroin

2. Past Year Initiates of Specific Illicit
Drugs among Persons Aged 12 or
Older: 2013
2
Marijuana
Pain Relievers
2,427
1,539
1,180
751
603 601 563
824
169 128
32
Tranquilizers
Ecstasy
Stimulants
Cocaine
Inhalants
LSD
Heroin
Sedatives
PCP
0
500
1,500
1,000
2,000
2,500
3,000
hthttp://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.pdf
http://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUH
results2013.pdf

3. Opiate Abusers 19 Times More Likely
to Abuse Heroin
A 2013 report by the Substance Abuse and Mental
Health Services Administration (SAMHSA) shows that
people aged 12 to 49 who had used prescription pain
relievers non-medically were 19 times more likely to
have initiated heroin use recently (within the past 12
months of being interviewed) than others in that age
group (0.39 percent versus 0.02 percent). The report
also shows that four out of five recent heroin initiates
(79.5 percent) had previously used prescription pain
relievers non-medically.
http://www.samhsa.gov/newsroom/advisories/1308215815.aspx
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4. DEA REPORTS INCREASE AVAILABILITY
OF HEROIN
• DEA intelligence indicates that South American and Mexican drug
trafficking organizations have exploited this increased demand by
producing heroin with increased purity that is not only more readily
available, but also cheaper. That product enters the United States
primarily across our southwest border and, not surprisingly, the
amount of heroin seized there has increased nearly 300 percent
from 2008 to 2013. During roughly the same time period (2008 to
2010), heroin-related overdose deaths have increased by 45
percent. This disturbing increase may be attributable to increased
purity and a younger, less experienced user population. As the
Administration takes a multifaceted approach to curb the
availability of prescription-based painkillers on the illicit market,
those addicted to opioids who are not seeking medication-assisted
therapy may increasingly turn to cheaper or more easily-obtained
alternatives, such as heroin.
Centers for Disease Control and Prevention, National Center for Health Statistics (accessed
February 11, 2013) http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5729a1.htm
http://www.justice.gov/dea/pr/speeches-testimony/2014t/043014t.pdf

5. DEA DEPUTY ASSISTANT ADMINISTRATOR
Congressional Testimony Indicates Increased Heroin
Use Linked to Prescription Medicine Abuse
According to the most recent National Survey on Drug Use
and Health (NSDUH), there were 335,000 current heroin
users in 2012, more than double the number in 2007
(161,000). The DEA believes the increased heroin use is
driven by many factors, including an increase in the misuse
(e.g., using more than medically indicated or using in a
manner not medically indicated) and abuse (i.e., using in
order to feel the psychoactive effects of the drug) of
prescription psychotherapeutic drugs, specifically opioids.
Increases in heroin purity and availability, the low street cost
of heroin, expanded Mexican Drug Trafficking Organizations’
involvement in the distribution of heroin, and the lack of
public awareness of the risks of heroin use are also
important contributing factors.
http://www.dea.gov/pr/speechestestimony/2014t/042914t.pdf

6. CDC Reports Links Between Heroin Use and
Prescription Drug Abuse Used in DEA Administrator’s
2014 Congressional Testimony
Recently, the Centers for Disease Control and Prevention (CDC)
reported that 38,329 people died from a drug overdose in the United
States in 2010, the most recent year for which information is available.
Nearly 60 percent of those drug overdose deaths (22,134) involved
prescription drugs. And of those deaths, 75 percent (16,651) involved
an opioid analgesic, also known as prescription painkillers. These
deaths represent not just a statistic, but our family members, friends,
neighbors, and colleagues. Years of over prescribing prescription
painkillers and decreased perception of risk associated with drug use,
particularly opiate abuse, has created too many new addicts. The rates
are alarming: in 2011, 2.1 million Americans abused or were dependent
to opioid pain relievers and 438,000 were addicted to heroin.
Drug Overdose in the United States: Fact Sheet. www.cdc.gov/homeandrecreationalsafety/overdose/facts.html (accessed March. 18, 2014).
Muhuri, et al. Associations of Nonmedical Pain Reliever Use and Initiation of Heroin Use in the US. Center for behavioral Health Statistics and QualityData Review. SAMHSA (2013). 2013.
http://www.justice.gov/dea/pr/speeches-testimony/2014t/043014t.pdf
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7. Heroin Traffickers Adapting to Opiate
Abusing Population
• DEA intelligence reveals that heroin trafficking
organizations are relocating to areas where
non-medical use of prescription drugs on the
rise. Correspondingly, NFLIS shows an increase
in the heroin cases and reports.
http://www.dea.gov/pr/speeches-testimony/2014t/042914t.pdf

8. NFLIS Estimates
2008 2009 2010 2011 2012 Jan-June 2013
Heroin Reports 95,879 112,153 110,393 119,765 131,624 74,049
Heroin Cases 73,562 83,535 82,385 88,924 99,830 55,744
Total Reports 1,711,763 1,758,505 1,713,360 1,660,216 1,622,435 770,851
Total Cases 1,290,363 1,297,735 1,274,383 1,218,161 1,189,089 578,034
% Heroin Reports 5.60% 6.38% 6.44% 7.21% 8.11% 9.61%
% Heroin Cases 6.92% 7.95% 8.04% 9.24% 10.72% 12.25%
http://www.dea.gov/pr/speeches-testimony/2014t/042914t.pdf
In NFLIS, a “case” is a law enforcement investigation; a “report’’ is an analysis of an
exhibit pertaining to an investigation. There are typically many reports in a single
case.

9. US Heroin Seizures
2009 - 2013
http://www.dea.gov/resource-center/dir-ndta-unclass.pdf
Source: National Seizure System

10. Heroin-related Emergency Department Visits
2007 - 2011
Source: Drug Abuse Warning Network
http://www.dea.gov/resource-center/dir-ndta-unclass.pdf

11. Heroin Use Among Pain
Patients Prescribed Opioids

12. Methods
• Retrospective review of 171,061 urine
samples
• All patients prescribed opioids for pain
• Samples evaluated for the presence of
– Heroin metabolite (6-monoacetylmorphine)
– Other illicit drugs
– Non-prescribed medications
– Prescribed medication
Heroin Use Among Pain Patients Prescribed Opioids Pain Week 2014

13. Overall Results
• 1.3% of samples tested positive for 6-MAM
• Why is this significant
– Detection time of 6-MAM in urine is up to 24
hours
Heroin Use Among Pain Patients Prescribed Opioids Pain Week 2014
Ameritox Data on file
Qiao Y et al Reaction pathways and free energy profiles for cholinesterase-catalyzed hydrolysis of 6-monoacetylmorphine Org. Biomol. Chem.,
2014,12, 2214-2227

14. Demographic Analysis
Heroin Use Among Pain Patients Prescribed Opioids Pain Week 2014

15. Percentage of samples with other
illicits found
Heroin Use Among Pain Patients Prescribed Opioids Pain Week 2014

16. Percentage of samples with a
non-prescribed medication found
Heroin Use Among Pain Patients Prescribed Opioids Pain Week 2014

17. Percentage of samples with a
non-prescribed medication found
Heroin Use Among Pain Patients Prescribed Opioids Pain Week 2014

18. Heroin mixed with other non-
prescribed or illicit drugs
• 20.3% tested positive for non-prescribed
sedative hypnotic
– 11.7% positive for heroin and sedative-hypnotic
– 4.4% positive for heroin, sedative hypnotic,
synthetic opioid
– 3.1% positive for heroin, sedative hypnotic, and
cocaine
– 1.1% positive for heroin, cocaine, sedative
hypnotic, and synthetic opioid
Ameritox Data on File

19. Heroin mixed with other
non-prescribed or illicit drugs
• 19.1% tested positive for cocaine
– 11.3% positive for heroin and cocaine
– 3.6% positive for heroin, cocaine, synthetic opioid
– 3.1% positive for heroin, cocaine, and sedative
hypnotic
– 1.1% positive for heroin, cocaine, sedative
hypnotic, and synthetic opioid
Ameritox Data on File

20. Conclusions
• Samples from patients prescribed opioids
that tested positive for heroin were more
likely to test positive for other illicit drugs,
such as cocaine and marijuana.
• In addition, they were more likely to test
positive for other non-prescribed
medications and negative for medications
that were prescribed.
• Clinicians should consider testing for heroin
use when conducting urine drug screens in
patients prescribed opioids.

21. Ameritox and PRIUM Hospitality Suite
Located in Piedmont 3 on the 12th Floor
Tuesday, April 7: 9:00 AM– 12:00 PM
Meet with the presenters of the Ameritox Vision Session, “Gateway to Heroin:
Opioids”, and continue the discussion:
– Richard Tucker, former DEA Diversion Control Agent
– Toni Torsch, founder of the Perry Hall, Maryland chapter of GRASP (Grief Recovery After
Substance Passing), and the Daniel Carl Torsch Foundation
Meet the Ameritox Toxicology Specialists: discuss test results, additional Ameritox
offerings, and see where your state ranks for illicit drug use, and the use of
prescription and non-prescription medications from the Ameritox National
Prescription Drug Report.
Wednesday, April 8: 11:30 AM– 1:30 PM
Michael Gavin, President of PRIUM, an Ameritox Solutions Provider.
Meet the Ameritox Toxicology Specialists: discuss test results, additional Ameritox
offerings, and see where your state ranks for illicit drug use, and the use of
prescription and non-prescription medications from the Ameritox National
Prescription Drug Report.