Transcript Novel Psychoactive Substances

ILLICIT SUBSTANCES &
SURVEILLANCE
Dr. Shaun Hosein
PHPM, University of Calgary
PHPC Symposium
May 24th, 2015
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Objectives
• Identify current trends in drug use.
• Explain Canadian Drug Use Surveillance
systems
• Describe Event-Based Surveillance
• Discuss Non-traditional data sources
Conflict of Interest
• None
Illicit Substances
Opioids
• Heroin
• Pharmaceuticals
Stimulants
• Cocaine
• Amphetamines
• Novel Psychoactive Substances
Cannabis
Depressants
Dissociatives
Hallucinogens
The Recreational Drug Market
Traditional Market
• Consistency and Content
Evolution of the market
• Synthetic Substances
• Prescription Drugs
• Adulteration
Evolution
• Amphetamines /
Methamphetamine
• MDMA
• Novel Psychoactive
Substances (NPS)
• Designer Drugs
• ‘Bath Salts’ – Cathinone
• Synthetic Cannabinoids
Seized Products – Drug Analysis Service
Drug Analysis Service - 2014
Adulteration
• Contamination
• By-products of manufacturing
process
• Dilution
• Inert Substances added to bulk and
dilute illicit compounds
• Adulteration
• Pharmacologically active
substances added to illicit
compounds that are intended to be
synergetic
Adulteration
• Opiates
• Fentanyl
• Lead
• Cocaine
• Levamisole
• Phenacetin
• Ecstasy / NPS
• PMMA
Cocaine Adulterants in the GTA
• Jan 2013 – April 2014
• Cocaine positive Urine Drug Screens (610) from the
Greater Toronto Area
• St. Michaels hospital, Community Addiction Clinics
Substance
Positive
Contaminated Cocaine
33%
Cocaine + Levamisole
31%
Cocaine + Phenacetin
8%
Cocaine + Phenacetin + Levamisole
7%
Traditional Marketplace
Desired
EFFECT
Desired
PRODUCT
PRODUCT
HARM
‘Marketplace in Flux’
Desired
EFFECT
Desired
PRODUCT
PRODUCT
X
HARM
Is there a problem?
• Harm can occur in numerous ways
• Populations are very difficult to access and understand
• Dr. Alexander Langimur, NEJM, 1963
• CDC Director of Epidemiology
• Context at that time
• Malaria / Polio / Influenza
‘The careful watchfulness over the distribution and
trends of occurrence through the systematic
collection, consolidation, and evaluation of
mortality and morbidity’
Purpose
1) Identify public health problems
• Communicable disease / Population Exposures
2) Stimulate public health intervention
• Information to plan, set priorities and evaluate the effects of public
health programs
3) Suggest hypotheses for epidemiological research
Maxcy – Rosenau 2007
Indicator based surveillance
• Passive / Active / Sentinel Surveillance
• Traditional Sources of Illicit Drug Intelligence:
• Canadian Community Health Survey
• Canadian Alcohol and Drug Use Monitoring Survey
• Ontario Student Drug Use and Health Survey
• Coroners Reports
Event Based Surveillance
• Organized and rapid capture of information about events
that can be a risk to public health.
• Data is usually from Non-traditional sources
• Detect events that occur in populations not able to access
formal channels for reporting
• Direct Information from witnesses of real-time events
• Poison and tele-health services
• Indirect Information
• Communication channels
• Social media or established routine alert systems
• Information channels
• news media, public health networks
Event Based Surveillance
Keller, M., (2009). Use of unstructured event-based reports for
global infectious disease surveillance. Emerg Infect Dis, 15(5),
689-695.
CCENDU Surveillance
• Canadian Community Epidemiology Network on Drug Use
• Investigate reported emerging issues related to drug use
• Communicate alerts and bulletins on topics of immediate concern
• Inform communities on lessons learned in responding to local drug
use issues
• Alerts / Bulletins
• June 2013 – Feb 2015 – 3 Alerts on Non-Pharmaceutical Fentanyl
• Sept 2014 – Drug-related Harms at Canadian Music Festivals​
• March 2014 - Synthetic Cannabinoids​
DOI: 10.1080/15563650902967404
ARTICLE
LCLT
Real-time surveillance of illicit drug overdoses using poison
center data
LEE S. FRIEDMAN
Heroin overdoses and real-time surveillance
Clinical Toxicology Downloaded from informahealthcare.com by University of Calgary on 05/07/14
For personal use only.
Division of Environmental and Occupational Health Sciences, School of Public Health, University of Illinois, Chicago, IL, USA; The Social
Policy Research Institute, Skokie, IL, USA
Background. In early 2006, government and media sources reported that crime syndicates were mixing fentanyl with heroin. This was
followed by an increase in heroin overdoses and opiate-related deaths. The most recent fentanyl outbreak illustrated the need for identifying
and establishing effective and responsive real-time surveillance tools to monitor drug overdoses in the United States. Objective. In this
study, poison call center data from Illinois were evaluated to determine whether the data could have detected the outbreak that occurred in
Illinois in early 2006 and whether it could be used for real-time surveillance. Methods. For this analysis, a two-step approach was used to
analyze potential heroin-related calls. First, the data were analyzed retrospectively to identify whether any significant temporal shifts occurred,
then a prospective analysis was conducted to simulate real-time surveillance. Results. Between 2002 and 2007, there were a total of 1,565
potential heroin-related calls, and the calls increased by 63.6% in 2006 compared to 2005. In the prospective analysis, the principal model
would have identified the outbreak in March 2006. Conclusions. If there had been a real-time surveillance program using poison center data,
the outbreak would have been identified 1 month before the initial postmortem reports to the Centers for Disease Control and Prevention at the
end of April 2006. Poison center data provide the potential for an earlier warning system than postmortem data sources, because the reports are
usually made within hours of the exposure. Poison center data can be effectively used to monitor heroin-related exposures.
• 2006 – Early reports of fentanyl adulterated heroin
• Retrospective and prospective analysis of PC 2002-2007
• 1565 potential heroin cases identified
• 63.6% increase in calls from 2005 to 2006
Keywords
Heroin; Fentanyl; Drug overdose; Surveillance; Real time; Poison center
• Spike in calls one month before first post-mortem case at
period of 1980–1988, the California lab responsible for
Introduction
the end
of April 2006
following the outbreak identified 112 overdoses because of
Toward the end of 2005 and early 2006, reports came out that exposures to 10 different illicit fentanyl analogues. Later in
crime syndicates were mixing fentanyl with heroin. This the 1980s and through the 1990s, there were other reports of
• Correlation
with reports
DEA
raidinand
reduction
deaths
of fatal fentanylin
overdoses
occurring in Pittsburgh,
was followed by confirmed
of an increase
heroin outbreaks
11
1–4
overdoses and opiate-related deaths from medical examiners.5 The largest number of reported deaths occurred in
Chicago.5 Fentanyl is an opiate with a far lower effective
dose and lethal dose than heroin. In opiate-naïve individuals,
the minimum lethal dose of heroin has been reported to be as
low as 10 mg6–8 compared to approximately 0.25 mg for fentanyl.8,9 There are various fentanyl analogues found in street
drugs, but the most commonly reported analogues are
a-methylfentanyl and 3-methylfentanyl.10
This was not the first time drugs mixed with fentanyl were
PA,12 Minneapolis, MN,13 and Patterson, NJ.14 Overdoses from
fentanyl abuse have also been reported in Finland and Russia.15
The most recent fentanyl outbreak illustrated the need for
identifying and establishing effective and responsive realtime surveillance tools to monitor drug overdoses in the
United States.5 All previous reports of fentanyl overdoses in
the United States have relied upon postmortem data. Although
information about deaths is important, there is a greater
reporting lag between the overdose
event
and the postmortem
Clinical
Toxicology
(2009) 47, 573–579
confirmation compared to other data sources that gather infor-
Poison Centre Data
Poison
Centre
Data
GPHIN
Drugs of abuse calls to OPC (2009-2013)
1542
Calls to Ontario Poison Centre
1600
1400
1200
1000
800
600
400
286
0
0
357
223
200
40
380
342
311
0
0
42
9
1
64
109
102
30 2
14 3
53
6
0
2009
2010
Synthe c Cathinones
2011
Synthe c Cannabinoids
2012
Methamphetamine
2013
Cocaine
Total
Digital Sources
• Social media has facilitated the access to a wealth of
information and new non-traditional data sources
• Google Trends  Google Flu watch
• Twitter /New Feeds
• Facebook
• Evolving area  ‘Rumor surveillance’
• Use of cell phone data in developing nations
• Participatory Epidemiology  Empowerment
What can we do now?
• Basic understanding of Illicit drug Evolution and
Adulteration
• ‘Marketplace in Flux’
• Awareness of Resources and Intelligence
• Poison Centres
• Medical Consultation
• CCENDU (www.ccsa.ca)
• National picture and trends
• Local Resources
• Towards the Heart (BC)
• Research Group on Drug Use (Toronto)
• Improved organization and capacity
• Strategies and Policies
Thanks
• Dr. Margaret Thompson(OPC)
• Dr. Matthew Young (CCSA)
• Dr. Jane Buxton (BCCDC)
• Dr. Shamir Mukhi (CNPHI)