Transcript Open slide - CTN Dissemination Library

The intranasal heroin epidemic among Latino adolescents in Texas: they're
calling it "cheese."
Carlos F. Tirado1; Jane C. Maxwell2; Bryon H. Adinoff1
1University
of Texas Southwestern Medical Center, Division on Addictions and NIDA Clinical Trials Network, Texas Node; 2University of Texas at Austin, Addiction Research Institute
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.”
Concerning Trends:
Demographic Characteristics
Heroin Deaths by Age in Dallas County:
(18 and under)
• Increase in percentage of deaths in persons less than 30 y/o*
90
80
9
60
14
50
40
“Cheese” is the combination of black tar heroin with
OTC sleep medications containing diphenhydramine
or doxylamine succinate. Average purity ranges from
2-5% heroin.
15
20
9
10
11
16
10
14
26%
7%
3
2002
22
5
6%
2003
18%
10
13%
33%
26%
3
14
8%
2004
16
2005
30-39
21-29
20
21
40-49
15
10
5
50+
**
7
15
20
30
0
27
11
4
11
30%
23%
2006
17
30%
7
12%
2007
* 97% of all heroin related deaths were found to have co-occurring substances at autopsy :
53% + Cocaine; 36% + Alcohol; 23% + Cannabis; 20% + Benzodiazepine
80%
70%
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%
•
60%
50%
40%
30%
For ages 15-19, Marijuana (32%) and Cocaine (16%)
were most common second drugs of choice
•
Percent with co-morbid psychiatric problems: 24%
10%
20
07
20
05
20
03
20
01
19
99
19
97
0%
19
95
- 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
Percent with any IV use (lifetime): 9.1%
•
20%
19
93
Distribution of intranasal heroin admissions by ZIP code:
• Increase in percentage of Hispanics entering treatment statewide
for heroin dependence between 1989-2007 (TEDS data)
19
91
Geographically “Confined” to Dallas
County
Rationale derived from RCTs:
Avg age at admission: 16.4 y/o
•
Disproportionate Impact on Hispanics:
19
89
Dallas County health commissioner convened a citywide task force to organize education, prevention and
treatment strategy
•
15-20
** Deaths recorded up to 07/01/2008
Community mobilized following highly publicized
overdose deaths and presentation of children as
young as 9 years of age in acute heroin withdrawal
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.
(Dallas County admissions data 2005-08)
8
70
Evidence-Based Intervention in Community
Treatment Center (CTP)
•
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
Program Details
Total by ZIP Code
- Patients stabilized for extended
treatment within residential program
130
24 hrs
Clinical/Behavioral Charateristics (n=25)
Dallas YRBS Survey: 2005 and 2007
• Relative Increase in percentage of school age Hispanics using
intranasal heroin in Dallas
12
1
10.4
10
Yearly Distribution 2005-2007
All Students
6
4
Yearly Distribution of intranasal heroin admissions by ZIP:
•
7.8
8
•
Hispanic
3.3
2.6
2
2005
18
9
0
2006
30
~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
15
0
35
0
Tylenol PM
TEDS data: 1989 to 2007
• Decline in average age of admission for heroin inhalers statewide.
40
35
27
15
10
5
20
07
20
05
20
03
20
01
19
99
19
97
19
95
19
93
0
19
91
- 90 day supply of Bup/Nal provided
by insurer at no cost
- Medication is dispensed in weekly
Nexus Recovery
IOP, Family tx
+
Bupe/Nal
Extended Treatment
Two week med
Taper
+
Transition to SOP
intervals, supply kept by CTP
medical staff
- Family group visit is yoked to
10 weeks
weekly medication visit
Preliminary results for 8 females
entering pilot program since 10/2007:
Figure Legend
1
2
20
19
89
• Cases in 75220 ZIP originating from specific high school
and middle school.
MAT and prepared for IOP
5-7 days
34
30
25
• Highest concentration of cases originating from the 75220
and 75217 ZIP codes.
patient and family are introduced to
2007-Ever Used Heroin &
2007
70
Transition to
school, job,
normative
behavior
Majority (>95%) of regular users were directly
purchasing black tar heroin and mixing it with OTC
sleep aids for personal use
•
0
2005-Ever Used Heroin
Majority (>90%) of teens bought or were given first
doses as powder
Emergency Room
or Detox Facility
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 19th, 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
Patient #
11
- During brief residential stay,
Nexus Recovery
Residential
+
Bupe/Nal stabilization
+ Bupe
“clean” UDS
3
4
+ Bupe,
“dirty” UDS
but engaged
in treatment
5
6
7
AMA
Discharge,
Relapse
8
-14
0
14
28
42
56
70
84
98
112 126 140 154 168 182 196
Days post discharge