Transcript Epidemiology

Epidemiology
Steven Shoptaw, Ph.D.
October 7, 2004
Important Concepts in
Drug Abuse and Dependence
•
•
Prevalence: The total number or
percentage of cases of a disease in a
population at a given time
Incidence: The extent or rate of
occurrence, especially the number of new
cases of a disease in a population over a
period of time.
Definitional Problems
• Drug abuse/dependence is a behaviorally
defined “disease” or disorder
– No pathogens or biological indicators of the
condition
Medical/Biological
Understanding
“Addiction is brain disease.”
Alan Leshner, Ph.D.
Moral/Choice Model
“You can look at [scans of] brains all day.
They can be lit up like Christmas trees. But
unless a person behaves in a certain way, we
wouldn't call them an addict.”
Sally Satel, M.D.
Normal Development
• Teens and early adolescence marked by
regular sampling of mind-altering
substances, run-ins with the law, problems
with parents, financial problems, and
intense conflicted relationships
• The vast majority, however, resolve this
condition and become regular taxpayers
Differential
• No known medical condition
• No diagnosable psychiatric condition
– Axis I OR Axis II
• Behaviors don’t remit despite pressure from
powerful external forces (e.g., jail, spouse,
employer)
Natural History of Opioid Abuse
30
Days Used in 30
25
20
1st treatment
episode
Jail
15
10
5
Dependence Diagnosis
0
10
20
Abuse Diagnosis
30
40
50
60
70+
Decade of Life
Apologies to Doug Anglin
Natural History of Stimulant Abuse
12
Jail
10
Days Used in 30
1st treatment
episode
8
6
4
2
Dependence Diagnosis
0
10
20
30
40
50
60
70+
Decade of Life
Abuse Diagnosis
Apologies to Doug Anglin
Heavy Drinking Days in 30
Natural History of Alcohol Abuse
16
14
1st treatment episode
UCLA
12
10
8
6
$$
$$
4
2
0
Dependence Diagnosis
Abuse Diagnosis
10
20
25
30
35
40
45
50
60+
Decade of Life
Apologies to Doug Anglin
Sentinels
• Monitoring the Future
– 30 years of cross-sectional survey of 50,000 8th,
10th and 12th graders on drug use
– Online database, with tables and figures of
highest relevance available at:
www.monitoringthefuture.org
5+ Drinks, Last 2 Weeks
35
30
25
20
15
10
5
0
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
8th Grade
10th Grade
12th Grade
www.monitoringthefuture.org, 2004
Cigarettes, Past Year
www.monitoringthefuture.org, 2004
Cigarettes, 10+ Per Day
16
14
12
10
8
6
4
2
0
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
8th Grade
10th Grade
12th Grade
www.monitoringthefuture.org, 2004
Annual Prevalence of Illicit Drug
Use Index
www.monitoringthefuture.org, 2004
Methamphetamine Use, Past Year
www.monitoringthefuture.org, 2004
Amphetamine Use, Past Year
www.monitoringthefuture.org, 2004
LSD Use, Past Year
www.monitoringthefuture.org, 2004
More Sentinels
• National Household Survey on Drug Abuse
(NHSDA)
• Drug Abuse Warning Network (DAWN)
• Drug and Alcohol Services Information
System (DASIS)
• Community Epidemiology Work Group
(CEWG)
• Clinical Literature
Prevalence - NHSDA, 2000
Illicit Drug Use
Percent Admitting
45
40
35
30
25
Males
Females
20
15
10
5
0
Ever Used
Past Year
Past Month
Any Illicit Drug Use by Gender
Illicit Drug Use, Past Month 1999, 2000, 2001
Percent Admitting
8
7
6
5
1999
2000
2001
4
3
2
1
0
Any Drug
M.J.
Prescriptn
Cocaine
Prevalence – NHSDA, 2000
Cigarette Use by Gender
Percent Admitting
80
70
60
50
Males
Females
40
30
20
10
0
Ever Used
Past Year
Past Month
Cigarettes
• While 45% of Americans smoked in 1960s, 23%
of general population now smoke cigarettes (CDC,
2002; Giovino, 2002)
• ~430,000 Americans die of smoking-related
causes (Giovino, 2002)
• Treatment-refractory group (George & O’Malley
2004)
– Lower educational attainment, less interest in
behavioral treatments that assist cessation, and medical
psychiatric and substance abuse comorbidities
– Increasing percentage of smokers are women
Natural History of Smoking
• Early smokers (started before age 15) are
more likely to progress to daily smoking
than those who started smoking later
• Daily smokers more likely to be dependent
than non-daily smokers
• Quit attempts more successful for smokers
who begin after age 15
Kandel et al 2004
Smoking in Past Month by
Ethnicity - NHSDA, 2000
0
10
20
30
40
50
Cuban
Central/S.A.
Puerto Rico
Mexican
Vietnamese
Korean
Japanese
Filipino
Chinese
Am Ind/Alaska
Black
White
Substance Use by Cigarette
Smoking, Past Month, 2000
Percent Admitting
45
40
35
30
25
Smokers
NonSmokers
20
15
10
5
0
Any Illicit
Binge Etoh
Heavy Etoh
Phenomenology: Seriously
Mentally Ill Who Smoke
• Cigarette smoking associates with psychotic
symptoms in bipolar disorder (Corvin et al.,
2001)
• Schizophrenics often heavily dependent
smokers with great difficulty in cessation
(Dalack et al., 1998)
– Low motivation to quit; interaction between
nicotine and negative affective symptoms
(Ziedonis et al., 1997)
Epidemiology: SMI and Smoking
• 70-90% of chronic schizophrenics smoke
cigarettes (Glassman, 1993; George, 1997)
• In psychiatric outpatients, schizophrenics
have highest smoking rates (Hughes, 1992)
• Patients with bipolar disorder smoke at
higher rates than general population, but
lower than schizophrenics (Diwan et al.,
1998)
Substance Use, Past Year
by Serious Mental Illness: 2001
Percent Admitting
45
40
35
30
25
SMI
No SMI
20
15
10
5
0
Illicit Drug
Cigarettes
Binge Etoh
Percent Diagnosed
Past Year Substance Abuse or
Dependence by SMI: 2001
25
20
15
SMI
No SMI
10
5
0
Drugs/Etoh
Drugs Only
Etoh Only
Heroin Prevalence
• Across years and across cultures,
prevalence of heroin abuse is fairly stable at
about 1.5% of the adult population.
– Social upheaval linked to increases in heroin
abuse (Afghanistan, Iraq, Russia)
Cocaine Epi
• Cocaine abuse: 1.7 million Americans
– 400,000 crack cocaine abusers (SAMHSA,
2002)
– Concentrated in urban areas and in ethnic and
racial groups
• Primary reason for treatment admission in
African Americans after alcohol in LA
County
Methamphetamine Epi
• Methamphetamine abuse: 600,000 Americans
– Additional 500,000 abuse other amphetamine type
stimulants (SAMHSA, 2000)
• Fast growing problem with established use in
West, new problems in South and Midwest
(Rawson et al., 2002)
• 20% increase in treatment admissions (DASIS,
2003)
– Primary reason for admission in California after alcohol
• International problem in Europe, S.E. Asia,
Thailand, New Zealand and Australia
Meth+amphetamine, DAWN
www.oas.samhsa.gov, 2004
Eureka Police Department
A classic example of what using methamphetamine for five years
can do for your complexion.
1990
1995
The results of injecting illegal drugs into the muscle of an arm.
How to recognize a drug lab
Many people may be unaware that they're living near a meth
lab. Here are some things to look for:
•Late night secretive activity in a rural/farm area.
•Unusual, strong odors (like cat urine, ether, ammonia, acetone or other
chemicals).
•Residences or buildings with windows blacked out.
•Renters who pay their landlords in cash. (Most drug dealers trade
exclusively in cash).
•Lots of traffic - people coming and going at unusual times. There may be
little traffic during the day, but at night the activity increases dramatically.
•Excessive trash including large amounts of items such as: antifreeze
containers, lantern fuel cans, red chemically stained coffee filters, drain
cleaner and cold medicine.
•Unusual amounts of clear glass containers being brought into the home.
•The mixing of unusual chemicals in a house, garage or barn by persons not
involved in the chemical industry.
•Possession of unusual chemicals, such as large quantities of MEK,
Coleman Fuel, Toluene, Acetone or cold/allergy medications.
www.henrycty.com/sheriff/meth.html
Amphetamine Treatment, 2001
www.oas.samhsa.gov, 2004
Infectious Diseases Associated
with Substance Abuse
•
•
•
•
•
•
Infective Endocarditis
Gonorrhea/Syphilis/Chlamydia/other STDs
Pneumonia
Tuberculosis
Viral Hepatitis and Liver Disease
HIV
Infectious Diseases Associated
with Substance Abuse
• Infective Endocarditis (i.e., staphylococcus
aurcus)
– Frequent among IDUs
– 8-16% of hospital admissions for IDUs
– Organism colonizes skin, also includes drug,
adulterants, packaging, fluids
– Occurs mostly to right side of heart
– Most common symptom is chest pain, cough, fever,
chills, arthralgia
– Antibiotic treatment or surgery
Infectious Diseases Associated
with Substance Abuse
• Gonorrhea/Chlamydia
• Syphilis
– Associates with MSM and non-injection drug
use in Los Angeles County
HIV Serostatus of LA County
MSM Early Syphilis Cases
2002 (Provisional), n=406
Unknown
14%
HIV30%
HIV+
56%
Kerndt, 2003
Infectious Diseases Associated
with Substance Abuse
• Pneumonia
– Most common reason for hospitalization for
IDUs (38%)
– Depression of gag reflex causes aspiration
– Cigarette and other types of smoking damage
lung function
– Malnutrition hampers healing
– HIV complications
Infectious Diseases Associated
with Substance Abuse
• Pneumonia (Cont’d)
– Fever, cough, chest pain, and breathing
problems for several weeks
– Pneumococcal pneumonia most common in
substance abusers
– Chest X-Rays, sputum sample, blood cultures,
arterial blood gases
– IV antibiotics treatment
Infectious Disease Associated
with Substance Abuse
• Tuberculosis – about 1,000 active cases in
LAC, 2003
–
–
–
–
Mycobacterium tuberculosis
Airborne transmission
10% of infected individuals develop active TB
More common among debilitated and
immunocompromised – substance abusers
Homeless HealthCare, LA 2004
Infectious Disease Associated
with Substance Abuse
• Hepatitis
– Hep A, B, C, D…
– 41-48% of IDUs have history of acute hepatitis
– 2/3 have abnormal liver transaminase (AST, ALT,
GGTP)
– Hep A transmitted fecal-oral
– Hep B transmitted through body fluids
– Non A/Non B (Hep C) transmitted through injection
and via sex
Infectious Diseases Associated
with Substance Abuse
• Liver Disease
– 2/3 have abnormal liver transaminase (AST, ALT,GTP)
– Alcohol directly hepatotoxic, other drugs contribute
– Methadone is NOT hepatotoxic - Naltrexone is at very
high doses
– Cocaine is hepatotoxic in animals and in humans at
high doses
– Cocaine hepatotoxic associated with hypotension and
renal failure
– Ethanol + Cocaine = Cocaethylene, extremely
euphoragenic and toxic
Infectious Diseases Associated
with Substance Abuse
• HIV
–
–
–
–
IDU and sexual behavior risks
IDU rate high in East (esp. among AA and LA)
IDU rate low in West
Value of testing and counseling in counseling
Epi Can Strongly Inform HIVRelevant Research
• Causality: Drug risks vary. While injection risk
behaviors are directly tied to drug use, sexual risk
behaviors are only associated with drug use
• HIV Prevalence: Prevalence factors strongly inform the
value of specific HIV-research programs
– IDU-specialized HIV prevention research may have more
value in East, Midwest, and South
– Drug-related sexual risk reduction focus may have more value
in West
• Drug by Risk Interaction: Local differences in
prevalence rates for specific drugs can direct the work
U.S. Adult Male AIDS Cases by Risk Behavior by Year
90
80
70
60
50
40
30
20
10
0
MSM
MSM+IDU
IDU
Hetero
Other
CDC, 2004
1990 1991 1992
1993 1994 1995 1996 1997 1998
1999 2000 2001
L.A. County Adult Male AIDS Cases by Risk Behavior by Year
90
80
70
60
50
40
30
20
10
0
MSM
MSM+IDU
IDU
Hetero
Other
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
L.A. County
HIV Epi
Pgm, 2004
U.S. Adult Female AIDS Cases by Risk Behavior by Year
70
60
50
IDU
Hetero
Other
40
30
20
10
CDC, 2004
0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
L.A. County Adult Female AIDS Cases by Risk Behavior by Year
70
60
50
IDU
Hetero
Other
40
30
20
10
0
1990
1991 1992 1993
1994 1995
1996 1997
1998 1999 2000
2001
L.A. County
HIV Epi
Pgm, 2004
Local Prevalence Data Sharpens
Understanding of HIV Epidemic
In Los
Angeles
County,
heroin
injectors at
low risk; gay
male meth
users at
extreme risk
70
60
50
40
30
20
10
0
MMT-LAC
Her-LAC Meth-HWD Meth-RC
LAC HIV Epi (1999-2004); UCLA/ISAP (1998-2004)
Methamphetamine and HIV in MSM: A
time-to-response association?
100
Percent HIV+
80
60
40
20
0
Probability
Sample1
Street
Recreational Outpatient Residential5
Outreach2
User3
Drug free4
1Deren et al., 1998, Molitor et al., 1998; 2Reback et al., in review;
3Reback, 1997; 4Shoptaw et al., 2002; 5VNRH, unpublished data
The End
• Open Every Talk with Local Epi
• Use Social Math to Drive Home the Point
– Make comparisons that are easy to understand
and that use charts – not tables