Patterns of and Trends in Substance Use In Florida:An Update

Presented by:Kelly K. Gurka, MPH, PhDAssistant Professor of Epidemiology, University of Florida

20 November 2019

Learning Objectives

After attending this webinar, participants are expected to be able to:• Characterize the decline in overall substance-related mortality in

Florida;• Differentiate between substances that were involved in a larger

number of deaths in 2018 than 2017 and those that were involved in a smaller number of deaths in 2018 than 2017, and

• Identify the new drug that is now included in substance-related surveillance conducted by the Medical Examiners Commission as well as the new substance that districts began reporting in 2018 (that will be required statewide in 2020).

Introduction

Brief update to the 2019 Annual Report, Patterns and Trends of Substance Use Within and Across the Regions of Florida. Based on data released after the 2019 Annual Report was prepared. Additional data became available after the data for the update were

compiled. Florida Youth Substance Abuse Survey data will be included in the 2020 Annual Report as a result. In addition, any state-specific data that become available from national surveillance efforts will also be included.

Data Sources

Based on data released following the preparation of the 2019 Annual Report National Survey on Drug Use and Health (NSDUH), sponsored by the

Substance Abuse and Mental Health Services Administration (SAMHSA) Behavioral Risk Factor Surveillance System (BRFSS), sponsored by the Centers

for Disease Control and Prevention (CDC) Drugs Identified in Deceased Persons by Florida Medical Examiners: 2018

Interim Report, prepared by the Florida Medical Examiners Commission Interim reports include data from January – June for their respective years.

Florida Estimates of Population, 2018, published by the Bureau of Economic and Business Research at the University of Florida

Florida by Geographic Region, Managing Entity, County

Managing Entities

Big Bend Community Based Care, Inc. (BBCBC). Comprised of 18 counties in the Panhandle.Lutheran Services Florida, Inc. (LSF). Comprised of 23 counties in North Central and Northeast FL .Central Florida Cares Health System, Inc. (CFCHS). Comprised of four counties in Central FL.Central Florida Behavioral Health Network, Inc. (CFBHN). Comprised of 14 counties in Central FL.Southeast Florida Behavioral Network, Inc. (SEFBHN). Comprised of five counties in Southeast FL.Broward Behavioral Health Coalition, Inc. (BBHC). Broward County.South Florida Behavioral Health Network, Inc. (SFBHN). Comprised of two counties in South Florida.

Alcohol

Under-age drinkingNationally, the general trend in the decline of alcohol use over time

among 12 – 17 year olds continues. Slight increase in alcohol use among adolescents in Florida mimicked

that of the nation as a whole in 2017.Without latest data, it is unknown whether Florida youth experienced

the same decline in current underage drinking as American youth overall.

Prevalence of past 30-day alcohol use among adolescents aged 12-17 years, Florida and US, 2006 -2018

16.8 16.215.3

14.412.6 12.5 12.8 12.3

10.79.2 9.9

17.1 16.114.7 14.8

13.613.1 12.9

11.3 11.79.9

9.110.0

9.0

0.0

2.5

5.0

7.5

10.0

12.5

15.0

17.5

20.0

22.5

25.0

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Rate

of p

ast 3

0-da

y al

coho

l use

(%)

Florida USA

Data source: NSDUH

Alcohol

Under-age binge drinking• Patterns observed for current drinking also observed for binge

drinking.• Prevalence continues to decline over time.• Prevalence in Florida tracks closely with the nation, though it saw a

slight increase in the last available state-specific data.• Without latest data, it is unknown whether Florida youth experienced

the same decline in binge drinking as American youth overall.

Prevalence of binge drinking among adolescents aged 12-17 years, Florida and US, 2006-18

10.49.6

8.27.6

6.9 6.86.4

5.64.9 5.1

10.69.9

8.7 8.87.8

7.3 7.16.2 6.2 5.9

4.75.3

4.7

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

10.0

11.0

12.0

Rate

of b

inge

drin

king

(%)

Year

Florida USA

Data source: NSDUH

Florida Youth Alcohol Use

• Based on newly released data from the Florida Youth Substance Abuse Survey (FYSAS; conducted spring of 2019), fewer Florida high school students endorsed current (past-30-day) underage drinking and binge drinking than in 2018.

• Continues downward trend in alcohol use that began in 2004.• Continues downward trend in binge drinking that began in 2006.

• However, more Florida middle school students endorsed both current underage drinking and binge drinking.

• First increase in past-30 day use since 2004.• First increase in binge drinking since 2010.

Alcohol

Alcohol use among adults• Remains largely unchanged overtime.• Prevalence among Floridians tracks very closely with the national

prevalence.

Prevalence of past 30-day alcohol use among adults, Florida and the US, 2006-2017

53.6 51.355.3 55.3 54.4 52.7 52.4

52.2 51.9 52.1 53.0 52.0 53.5 54.0

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

Past

30-

day

drin

king

(%)

Florida USA

Data source: NSDUH

Alcohol

Binge Drinking among Adults• Binge drinking is often used as an indicator of problematic drinking.• Binge drinking among Floridians tracks lower than the nation as a

whole.• Changes over time in national prevalence reflected in Florida.• However, in last year, the prevalence nearly converges.

Prevalence of binge drinking among adults, Florida and the US, 2006-2018

Data source: BRFSS

13.8 13.0 13.716.5

15.0 15.5 15.1 15.8

15.1 15.1 14.816.8 16.0 16.9 17.4

16.2

0.0

5.0

10.0

15.0

20.0

25.0

30.0

Bing

e dr

inki

ng (%

)

Florida USA

Alcohol

Current trends continue based on updates to national data.• Prevalence of current alcohol use and binge drinking among

adolescents continues to decline.• Prevalence of current alcohol use and binge drinking among adults

has changed little to none.

Tobacco & Nicotine

• Tobacco use, of any kind, is a preventable cause of not only a number of diseases but also deaths.

• However, as conventional tobacco product use declines, the use of nicotine-containing products is on the rise.

• At the time data were compiled for this report, Florida-specific updates to adolescent use data were not yet available.

Combustible Cigarettes

• At the time data was compiled for this report, Florida-specific updates to adolescent use data were not yet available.

• Adolescent use of cigarettes continues to decline markedly.• Compared to adolescents, cigarette smoking is more prevalent among

adults in both Florida and the US.• Adult use of cigarettes is trending downward, but at a much slower

rate.

Past 30-day use of conventional cigarettes among youth aged 12 – 17 years,

Data source: NSDUH

9.5 9.18.3 8.0

6.95.6

5.04.4

3.62.9 2.8

10.49.9

9.2 9.08.4

7.8

6.65.6

4.94.2

3.4 3.2

0.0

2.0

4.0

6.0

8.0

10.0

12.0

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

% o

f pas

t 30-

day

use

Year

Florida USA

Past 30-day cigarette smoking among adults, Florida & US, 2009-2017

Data source: BRFSS

21.119.3

17.5 17.1 17.219.3 17.7 16.9

17.7

15.8 15.516.1

19.6 19.4

18.4 17.9 17.120.1

18.8 18.2 17.316.7 16.3 16.3

0.0

4.0

8.0

12.0

16.0

20.0

24.0

28.0

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

% o

f pas

t 30-

day

use

Florida USA

E-cigarettes

Adolescent use is on the rise, while adult use is on the decline according to recent data, which is limited.

Lifetime and past 30-day use of e-cigarettes (by sex and school level, Florida, 2016 and 2018

Data source: FYSAS

25.8

9.6 10.68.4

5.1

12.8

27.1

13.7 14 13.5

6.4

19.2

0

5

10

15

20

25

30

Lifetime Past 30-day use Male Female Middle school High school

% o

f e-c

igar

ette

use

2016 2018

Prevalence of vaping among adults 18 years of age and older, Florida and the US, 2016-2017

Data source: BRFSS

21.620.4

20.219.1

4.54.4

4.7

4.3

4.0

4.2

4.4

4.6

4.8

5.0

5.2

5.4

5.6

5.8

6.0

10.0

12.0

14.0

16.0

18.0

20.0

22.0

24.0

26.0

2015 2016 2017 2018

Rate

of e

-cig

use

(%)

Lifetime use (USA) Lifetime use (FL)Past 30-day use (USA) Past 30-day use (FL)

Tobacco & Nicotine

• Continued progress is being made in the prevention or cessation of conventional tobacco products.

• However, vaping poses a new risk.• Though nicotine-containing products were designed, at least in part,

as an alternative to tobacco products, use of these products is lower in FL among adults than among adolescents, most of whom are likely nicotine naïve at initiation.

Marijuana

• Updates to Florida-specific data (YBRSS or FYSAS) for youth were not available at the time data were compiled for the Update Report.

• Nationally, new data suggest that the prevalence of marijuana use among both adolescents and adults continues to rise.

• These increases may be a harbinger for such an increase in Florida given the prevalence of marijuana use in Florida was already outpacing that of the nation.

Prevalence of past 30-day marijuana use among adolescents aged 12-17 years, Florida and the US, 2006-2018

Data source: NSDUH

6.9

6.6 6.36.9 6.8 7.0

7.5 7.5

6.8

7.07.5

6.5

6.7 6.77.2

7.67.0 7.3

7.1

7.4 7.16.4 6.6 6.7

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

10.0

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Rate

of p

ast 3

0-da

y m

ariju

ana

use

(%) Florida USA

Marijuana

• American adults are also increasingly using marijuana.• Though Floridian adults lagged just behind the nation with regard to

prevalence of current use of marijuana, increases in Florida appeared to begin accelerating in 2016-2017, perhaps in anticipation of or response to legislation passed in 2016 and enacted in 2017.

Prevalence of past 30-day marijuana use among adults aged 18 years or more, Florida and the US

Data source: NSDUH

5.4 5.5 5.8 6.0 6.3 6.6 7.0 7.6 7.9 7.78.8

6.0 5.7 6.16.6 6.9 6.9 7.3 7.6

8.6 8.59.0

9.810.5

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

Rate

of p

ast 3

0-da

y m

ariju

ana

use

(%) Florida USA

Novel Psychoactive Substances

• The proliferation of new synthetic drugs, collectively known as novel psychoactive substances, pose a particular public health challenge.

• Three of the four reported in the April 2019 Annual Report, are included in the interim report of the Medical Examiners Commission.

• Only one increased – synthetic cathinone – from the first half of 2017 to 2018, with 122 deaths involving this drug.

• Though this is a relatively small number of deaths, nearly 3 of every 5 (n = 73) decedents in whom the drug was detected died as a result of the synthetic cathinone poisoning.

Opioids - Prescription

• First half of 2018 saw another subsequent year of an increase in fatal prescription opioid overdoses, with 216 cases occurring in the first half of 2018 compared to the first half of 2017.

Number and % of deaths involving prescription opioids among all deaths involving substances, Florida, January-June 2013-2018

Data source: 2013 – 2018 Interim Reports of Drugs Identified in Deceased Persons by Florida Medical Examiners

2575 25533077

3898 4231 4447

61.9 63.5 65.772.3 69.2

75.1

0

10

20

30

40

50

60

70

80

90

100

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

2012 2013 2014 2015 2016 2017 2018 2019

Perc

ent

Num

ber

Deaths with the drug detected% Deaths caused by the drug

Opioids - Prescription

• The number of deaths involving most types of prescription opioids declined in the first half of 2018 compared to the first half of 2017.

• Exceptions include hydromorphone, buprenorphine, and most notably, fentanyl.

• Though fentanyl is available by prescription, it is likely that many cases involving fentanyl are due to illicit fentanyl rather than misuse of prescription fentanyl. The increase in fatal prescription opioids is driven nearly entirely by the fentanyl-caused deaths.

Number of deaths with different types of opioids detected among all deaths examined in Florida, January-June, 2013-2018

Data source: 2013 – 2018 Interim Reports of Drugs Identified in Deceased Persons by Florida Medical Examiners

0100200300400500600700800900

1000110012001300

2013 2014 2015 2016 2017 2018

Num

ber o

f occ

urre

nces

Buprenorphine

Codeine

Fentanyl

Hydrocodone

Hydromorphone

Meperidine

Methadone

Morphine

Oxycodone

Oxymorphone

Tramadol

Opioids - Fentanyl Analogs

After significant increases from 2016 to 2017, the number of decedents in whom fentanyl analogs was detected declined in 2018.

Number of decedents in whom fentanyl analogs were detected and caused death, Florida, January-June 2016-2018

Data source: 2013 – 2018 Interim Reports of Drugs Identified in Deceased Persons by Florida Medical Examiners

183 149

875 840

520437

0

100

200

300

400

500

600

700

800

900

1000

Fentanyl analogs detected Deaths caused by fentanyl analogs

2016 2017 2018

Opioids - Heroin

After four years of precipitous increases in the number of deaths involving heroin, fewer of these deaths occurred in the first half of 2018 compared to first half of 2017.

Number of deaths with heroin detected and number of deaths attributed to heroin, 2013-18

Data source: 2013 – 2018 Interim Reports of Drugs Identified in Deceased Persons by Florida Medical Examiners

70

156

343

434

548

452

68

140

320

406

509

397

0

100

200

300

400

500

600

2012 2013 2014 2015 2016 2017 2018 2019

Num

ber o

f dea

ths

Deaths with heroin

Deaths due to heroin

Opioids - Other

Beginning with the 2018 Interim Report, reporting of U-47700, a highly potent synthetic opioid, was included in the Drugs Identified in Deceased Persons by Florida Medical Examiners 2018 Interim Report.• U-47700 or “U4” is also known as “pink” or “pinky” due to sometimes

being a light pink powder.• 33 occurrences were reported for January – June 2018.

Opioids - Other

Though not specifically requested by the Medical Examiners Commission for 2018, many districts began reporting deaths involving mitragynine, also known as kratom.• Reporting of mitragynine will begin for all districts by 2020.• 40 occurrences were reported for January – June 2018.

Cocaine

After four years of increases in the number of deaths involving cocaine, fewer of these deaths occurred in the first half of 2018 compared to first half of 2017.

Number of deaths with cocaine detected, and the number and % of deaths attributed to cocaine, Florida, 2013-2018

Data source: 2013 – 2018 Interim Reports of Drugs Identified in Deceased Persons by Florida Medical Examiners

668 725840

1144

15841469

291 343441

643

1029844

43.5647.31

52.5056.21

64.9657.45

0

10

20

30

40

50

60

70

0200400600800

100012001400160018002000

2013 2014 2015 2016 2017 2018

Perc

enta

ge (%

)

Num

ber o

f cas

es

Occurrences Cause of death % Cause of death

Cocaine

Number of deaths involving cocaine differ by Managing Entity region, though the general trend statewide has been an increasing number of deaths occurring over time.

Number of deaths with cocaine detected by Managing Entity region, Florida, 2013-2018

Data source: 2013 – 2018 Interim Reports of Drugs Identified in Deceased Persons by Florida Medical Examiners

0

50

100

150

200

250

300

350

400

450

500

2012 2013 2014 2015 2016 2017 2018 2019

Num

ber o

f occ

urre

nces

BBCBC BBHC CFBHN CFCHS LSF SFBHN SEFBHN

Methamphetamine

• No new data regarding use among youth were available when data were compiled for this update.

• The number of deaths involving and attributed to methamphetamine continued to increase in FL in 2018, with an increasing proportion of deaths involving methamphetamine being attributed to the drug.

Number of deaths with methamphetamine detected and the number and % of deaths attributed to methamphetamine, Florida, 2013-2018

Data source: 2013 – 2018 Interim Reports of Drugs Identified in Deceased Persons by Florida Medical Examiners

81109

130

237

414468

36 4063

114

213

274

44.4436.70

48.46 48.1051.45

58.55

0

5

10

15

20

25

30

35

40

45

50

55

60

65

0

100

200

300

400

500

600

2013 2014 2015 2016 2017 2018

Perc

enta

ge (%

)

Num

ber o

f Cas

es

Occurrences Cause of death % Cause of death

Stimulants

• With the exception of some modest slowing in the number of deaths due to cocaine in the latest reporting period, deaths involving and attributed to stimulants continues to be a growing public health concern.

Benzodiazepines

• Number of deaths in which benzodiazepines were involved decreased.

• Smaller percentage of deaths involving benzodiazepines were ruled to be caused by these drugs.

Number of deaths with benzodiazepines detected and number and % of deaths attributed to benzodiazepines, Florida, 2013-2018

Data source: 2013 – 2018 Interim Reports of Drugs Identified in Deceased Persons by Florida Medical Examiners

2287 2200 21822344 2506 2333

568 594 558 632 658 559

24.8427.00 25.57 26.96 26.26

23.96

0

5

10

15

20

25

30

35

40

0

500

1000

1500

2000

2500

3000

3500

4000

4500

2013 2014 2015 2016 2017 2018

Perc

enta

ge (%

)

Num

ber o

f Cas

es

Occurrences Cause of death % Cause of death

Number and proportion of different benzodiazepines detected among deceased persons, Florida, 2018

Data source: 2013 – 2018 Interim Reports of Drugs Identified in Deceased Persons by Florida Medical Examiners

Benzodiazepines

Fewer deaths occurring in the first half of 2018 in Florida involved prescription benzodiazepines compared to the first half of 2017, but these declines were not observed uniformly across the Managing Entity regions.

Number of occurrences and percent change of alprazolam and diazepam in decedents, Florida and by Managing Entity region, January – June 2018

ME RegionsAlprazolam Diazepam

2017 2018 % change 2017 2018 % changeFlorida 912 816 -10.5 312 290 -7.1

ME region

BBCBC 49 50 2.0 13 16 23.1

BBHC 86 57 -33.7 22 14 -36.4

CFBHN 254 229 -9.8 97 88 -9.3

CFCHS 117 112 -4.3 39 43 10.3

LFS 177 142 -19.8 69 60 -13.0

SFBHN 117 91 -22.2 24 30 25.0

SEFBHN 112 135 20.5 48 39 -18.8

Data source: 2013 – 2018 Interim Reports of Drugs Identified in Deceased Persons by Florida Medical Examiners

Recap

• Alcohol. Decline in use and binge drinking among youth; prevalence of use and binge drinking largely unchanged among adults.

• Nicotine. Combustible cigarette smoking continues to level off among youth, no new data for vaping among youth were available, and vaping among adults is declining nationally.

• Marijuana. Not only is marijuana use among both youth and adults increasing nationally, but the rise is accelerating. Based on previous years’ data, the trends in Florida are preceding the national trends.

Recap

• Opioids. Number of deaths involving most specific opioids declined in 2018 compared to 2017, with the most notable exception being fentanyl.

• Stimulants. Though deaths due to both cocaine and methamphetamine have increased in number for the four previous years, the number of deaths involving cocaine in 2018 was a decrease from 2017. Number of deaths involving methamphetamine continues to rise, however.

• Benzodiazepines. Both the number of deaths involving and the proportion of deaths attributed to benzodiazepines is declining in Florida.

Data Sources

• Bureau of Economic and Business Research. Population Studies Program. Florida Estimates of Population 2018.

• Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System (BRFSS).

• Florida Department of Law Enforcement. Drugs Identified in Deceased Persons by Florida Medical Examiners, Interim Reports 2013-2018.

• Florida Department of Law Enforcement. Annual Uniform Crime Reports.

• Substance Abuse and Mental Health Services Administration (SAMHSA). National Survey on Drug Use and Health (NSDUH).

Questions?

Contact:

Kelly K. Gurka, MPH, PhDkgurka@ufl.edu