rx16 heroin tues_200_1_allen-harocopos_2willis

Preventing HeroinInitiation and Deaths

Presenters:• Bennett Allen, MA, Research Associate, New York City Department

of Health and Mental Hygiene• Alex Harocopos, MS, Senior Research Associate, New York City

Department of Health and Mental Hygiene• Aaron Willis, AM, LSW, PhD Candidate, Indiana University School

of Social Work

Heroin Track

Moderator: Grant T. Baldwin, PhD, MPH, Director, Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, CDC, and Member, Rx and Heroin Summit National Advisory Board

Disclosures

Bennett Allen, MA; Alex Harocopos, MS; Aaron Willis, AM, LSW, PhD Candidate; and Grant T. Baldwin, PhD, MPH, have disclosed no relevant, real, or apparent personal or professional financial relationships with proprietary entities that produce healthcare goods and services.

Disclosures

• All planners/managers hereby state that they or their spouse/life partner do not have any financial relationships or relationships to products or devices with any commercial interest related to the content of this activity of any amount during the past 12 months.

• The following planners/managers have the following to disclose:– John J. Dreyzehner, MD, MPH, FACOEM – Ownership interest:

Starfish Health (spouse)– Robert DuPont – Employment: Bensinger, DuPont &

Associates-Prescription Drug Research Center

Learning Objectives

1. Describe efforts to prevent Rx drug and heroin misuse and overdose fatalities.

2. Identify key transition points from opioid analgesic misuse to heroin initiation.

3. Examine the impact of heroin use in opiate-related overdose deaths.

4. Provide accurate and appropriate counsel as part of the treatment team.

Heroin initiation following non-medical opioid analgesic use in New York City: Results from the NYC RxStat Qualitative Component

Alex Harocopos and Bennett Allen Bureau of Alcohol and Drug Use Prevention, Care and Treatment (BADUPCT)New York City Department of Health and Mental Hygiene (DOHMH)

National Rx Drug Abuse and Heroin Summit29 March 2016

DisclosuresAlex Harocopos has disclosed no relevant, real, or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services

Bennett Allen has disclosed no relevant, real, or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services

Learning objectives1. Inform efforts to prevent Rx drug and

heroin misuse and overdose fatalities2. Identify key transition points from opioid

analgesic (OA) misuse to heroin initiation3. Examine the impact of heroin use in

opiate-related overdose deaths4. Provide accurate and appropriate counsel

as part of the treatment team.

Outline• The RxStat initiative• New York City unintentional overdose

mortality data• New heroin initiates overview

– Methods– Results– Summary

• Discussion

NYC RxStat• Public health and public safety collaboration housed at

NYC Department of Health & Mental Hygiene• Participants from city, state, and federal organizations

attend monthly meetings• Public health approach

– Track drug use and associated health and safety consequences at a population level

• “Real-time” (enhanced) surveillance• Timely, accurate analysis of drug misuse indicators

from multiple sources (e.g., mortality, EDs, PMP, drug treatment, law enforcement, etc.)

NEW YORK CITY UNINTENTIONAL DRUG POISONING DEATHS, 2000-2014

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 20140

100

200

300

400

500

600

700

800

900

0

2

4

6

8

10

12

14

638

792723

769722

796 838

695618 593

541630

730788 800

10.2

12.211.5 12.2

11.5

12.5

13.3

10.9

9.6 9.1

8.2

9.4

10.911.6 11.7

Number of unintentional poisoning deaths Age-adjusted rate per 100,000

Num

ber

Age

-adj

uste

d m

orta

lity

rate

per

100

,000

Unintentional drug poisoning deaths, NYC, 2000-2014

Source: New York City Office of the Chief Medical Examiner & New York City Department of Health and Mental Hygiene 2000-2014

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 20140

100

200

300

400

500

600

700

-1

1

3

5

7

9

11

457517 538 559

504557

607

480 468 451392

489563

611 629

7.3

88.6 8.8

88.7

9.6

7.5 7.2 6.9

5.9

7.3

8.49

9.2

Number of unintentional opioid-involved drug poisoning deaths Age-adjusted rate per 100,000

Num

ber

Age

-adj

uste

d m

orta

lity

rate

per

100

,000

Unintentional opioid poisoning deaths, NYC, 2000-2014


Rate of unintentional drug poisoning deaths by drug type, NYC 2000-2014

(Drugs not mutually exclusive)

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 20140

1

2

3

4

5

6

7

8

9HeroinCocaineBenzodiazepinesOpioid AnalgesicsMethadone

Age

-Adj

uste

d R

ate

per 1

00,0

00


White New Yorkers have the highest rates of unintentional drug poisoning deaths

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 20140

2

4

6

8

10

12

14

16

18

20

Age

-adj

uste

d ra

te p

er 1

00,0

00


White

Hispanic

Black

Rates of heroin-involved unintentional drug poisoning death increased by 152% among

New Yorkers aged 15-34, 2010-2014

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 20140

2

4

6

8

10

12

14

35-54 55-84 15-34

Age

-adj

uste

d ra

te p

er 1

00,0

00


NEW YORK CITY RXSTAT QUALITATIVE COMPONENT

Study overview• Opioid study conducted between July 2013 and January

2015• Qualitative methods chosen to contextualize surveillance

data• Three main aims:

– Circumstances of initiation into OA misuse– Trajectories of use including transition to heroin– Market dynamics

• Final sample included 93 in-depth interviews with persons with a history of OA misuse

Methods• Purposeful sampling used to reflect demographic

diversity and trends in non-medical OA use • Efforts to recruit from non-treatment population• Interviews were audio recorded and transcribed

for analysis• Thematic analysis conducted by the two authors• Present findings describe a subset of 31

participants who initiated heroin within the past five years following OA misuse

New heroin initiates: Demographics

• 31 participants• Median age 22 years• 25 male; six female• 30 non-Hispanic white• 15 currently enrolled in or had completed

further education (i.e., trade school, college, or graduate school)

• All reported stable housing

New heroin initiates:Drug use characteristics

• Median age at first OA misuse: 16 years• Median length of time between OA

misuse and heroin initiation: 3 years• 25 participants reported injection drug

use; 23 initiated injection following heroin use

• 26 participants reported physical opioid dependence prior to heroin initiation

Transition from OA to heroin Four key factors associated with transition:

1. Use of high dose OAs2. Intranasal route of administration3. Development of physical opioid dependence4. Dissolution of heroin stigma in social networks

• Trajectory toward heroin was similar, irrespective of whether OA initiation occurred recreationally or medically

1. Use of high-dose OAs• Some participants who started with dual-

compound pills were concerned about ingesting too much acetaminophen

• More experienced peers provided information about single-compound pills, facilitating transition

• Single-compound OAs are higher dose

“I remember specifically one guy telling me, asking me how many pills I take a day, as far as Percocets and Vicodins, and I was telling him I take, like, six, seven pills a day. And he was like ‘Dude, there’s this other thing called a roxy [oxycodone 30mg], a blue.’ He’s like, ‘You take one.’ He’s like, ‘All those pills you’re taking are fucking up your stomach.’ He was right. He was definitely right. You know, by the end of the day, I would feel horrible taking all those Percocets and Vicodins. My stomach would feel horrible.”

(Nick, age 28)

2. Intranasal route of administration

• Use of high dose OAs was often accompanied by a shift from oral to intranasal administration

• All but one participant favored sniffing OAs• Many participants had experience sniffing

other drugs (e.g. cocaine), prior to OAs• Little to no stigma associated with

intranasal OA misuse

“I didn’t start sniffing pills until later, when I started with the roxies, ‘cause you’re not gonna sniff Perc 10s. You know what I mean? It’s like sniffing an aspirin . . . It’s really weird. I think that they made these roxies to be able to sniff, because they taste great. They don’t burn your nose . . . Like, have you ever broken a Perc 10? You see how much chalk and powder is in there? It’d probably taste disgusting, probably burns your nose. But a roxy just has this sweet taste to it and it just has this great drip to it . . . It’s great. You don’t even feel nothing.”

(Philip, age 25)

3. Development of physical opioid dependence

• Participants were often unaware of the risks of physical opioid dependence

• Knowledge of dependence came after experiencing physical withdrawal symptoms

• Physical dependence tended to develop in short periods of rapidly escalating use

• Financial burden to sustain daily OA use• Heroin initiation often yoked to anticipation

and/or acute suffering of withdrawal symptoms

“I was taking six halves a day, and it started becoming every day, slowly but surely. It was never an overnight thing. Slowly but surely, and eventually it became really out of control. It took me two years to go from a quarter to a whole one, but it took me a couple of months to go from one to five, six, seven, eight a day. . . If you’re taking that much for that long, you’re not even taking it to get high. You don’t get high anymore. . . You just get okay. You can function. And if you don’t take, you get really sick. It was funny, because everybody always thinks they’re not going to withdraw. Nobody thinks they’re going to withdraw. ‘Nah, I’ll be fine.’”

(Joe, age 21)

“Heroin is like a dark word. It's like a danger. Like, heroin is the worst drug a person can do, but when you get sick from Percocet®, you are so sick you don't care. You just want that sickness to be gone. You don't care what the word is, heroin, how bad it is, how bad it sounds. You don't want to be sick. You want it gone. You know what I mean? If you had a gun and you were up in the mountains and you were sick, you'd probably shoot yourself. That's how bad it is. You don't even want to live when you're sick.”

(Harry, age 44)

4. Erosion of heroin stigma• Prior to initiation, most participants expressed

strong negative feelings toward heroin• Erosion of heroin stigma was linked to

physical opioid dependence • Some participants initiated heroin at the first

opportunity presented to them• Once heroin use had permeated a social

network, it was quickly accepted by peers

“I knew [heroin] was really bad . . . . But like I said, it was a disconnect at first—that heroin was completely separate than pain medication. I didn’t know that there was a one-to-one analogy. So first time, you know, I saw people doing it around me. You know, and I kinda felt uncomfortable. I walked out of the room. You know? And then my friends were like, ‘What the fuck are you doing? You take this shit all the time.’ And that’s when they explained to me that opiates, opium, heroin, same thing.”

(Neil, age 22)

Summary• Persons who already have a physical opioid

dependence may be receptive to heroin because it is cheaper and more readily accessible than OAs

• Stigma as a barrier to heroin use is quickly overcome in social settings

• Persons who are opioid dependent are particularly vulnerable when they are experiencing withdrawal symptoms

• Prevention efforts should focus on identified points of transition

Discussion• New heroin initiates did not tend to be

engaged with harm reduction services• Medication-assisted treatment (MAT) is

considered the gold standard of care for opioid dependence yet there is often stigma from medical and treatment professionals, as well as persons who use drugs around its use

• As heroin permeates new social networks, will future heroin initiates bypass OAs?

Opiate Related Overdose Deaths: Differences with Heroin or No Heroin in

the Blood?

Aaron C. Willis, AM, LSW, PhD(c)Indiana University School of Social Work

Disclosure Statement

• Aaron C. Willis, AM, LSW, PhD(c), has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.

Learning Objectives

1. Describe efforts to prevent Rx drug and heroin misuse and overdose fatalities.

2. Identify key transition points from opioid analgesic misuse to heroin initiation.

3. Examine the impact of heroin use in opiate-related overdose deaths.

4. Provide accurate and appropriate counsel as part of the treatment team.

Acknowledgements

• Marion County Coroner’s Office, Indianapolis, IN• Alfie Ballew, MBA, Chief Deputy Coroner

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130

5

10

15

20

25

5 5.2 5.76.9 7.5 8.1

8.910.2 10.6 10.7

10.9 11.312.2 12.2 12.9

2.4 2.6 3.4 3.2

5.1 6.37.2

8.8 9.4 9.5

12.2 12.213.1 13.6 14.2

1.6 1.3 2.1 1.6 1.7 2.5 2.33.9

6.6 6.5

15.2 14.615.8

19.6

21.5

Crude Prescription Painkiller and Heroin Death Rates

United States Indiana Marion CountyYear

Per 1

00,0

00 P

eopl

e

Centers for Disease Control and PreventionWONDER Online Database

Purpose of Study

1. Are people who die of overdose in Indianapolis similar to rest of country?

2. Can Coroner data facilitate the availability and distribution of naloxone to those at greatest risk?

Sources of Data• Death Certificate

– Gender, age, address, Veteran status, education• Autopsy Report/Toxicology Report

– All substances of misuse, psychotropic and health related medications

• Deputy Coroner’s Field Officer Report– Narrative of investigation– Previous medical, mental health, and substance misuse

history; previous overdoses; suicide attempts; recent release from incarceration or inpatient setting

• “Risk Factors”

Description of Study Subjects

• 2007 – 2014 overdose fatalities is Marion County• N = 1174• 64% Male (n=747)• 86% Caucasian (n=1005)• Mean age: 39.7 (SD=12.32)• 9% Veteran (n=100)• 76% HS diploma/GED or higher (n=884)• 38% Heroin in blood (n=451)• 62% No heroin in blood (n=723)

Subjects with Heroin in Blood

• N = 451• 77% Male (n=347)• 80% Caucasian (n=359)• Mean age: 38.02 (SD=11.98)• 9% Veteran (n=40)• 76% HS diploma/GED or higher (n=338)

Subjects with Heroin in Blood: Risk Factors

• 43% had a significant medical history (n=193)• 18% had a mental health history (n=81)• 94% had a substance misuse history (n=422)• 29% had intravenous use history (n=131)• 10% had a previous overdose (n=43)• 4% had a previous suicide attempt (n=20)• 13% were recently released from incarceration

or inpatient setting (n=57)

Subjects with Heroin in Blood: Polysubstance Use

• 26% tested positive for marijuana (n=115)• 28% tested positive for cocaine (n=127)• 29% tested positive for alcohol (n=130)• 47% tested positive for benzodiazepines (n=213)

– 68% for Xanax (n=144)– 34% for Klonopin (n=71)– 19% for Valium (n=39)

Subjects with No Heroin in Blood

• N = 723• 55% Male (n=400)• 89% Caucasian (n=646)• Mean age: 40.72 (SD=12.42)• 8% Veteran (n=60)• 76% HS diploma/GED or higher (n=546)

Subjects with No Heroin in Blood: Risk Factors

• 66% had a significant medical history (n=474)• 39% had a mental health history (n=281)• 74% had a substance misuse history (n=538)• 7% had intravenous use history (n=49)• 16% had a previous overdose (n=113)• 9% had a previous suicide attempt (n=64)• 6% were recently released from incarceration

or inpatient setting (n=40)

Subjects with No Heroin in Blood: Polysubstance Use

• 21% tested positive for marijuana (n=149)• 14% tested positive for cocaine (n=98)• 17% tested positive for alcohol (n=124)• 59% tested positive for benzodiazepines (n=426)

– 65% for Xanax (n=266)– 28% for Klonopin (n=113)– 20% for Valium (n=83)

Significant Differences Between the Two Groups

Significant• Gender**

• Race**

• Age**

• Medical Hx**

• Mental health Hx**

• Substance misuse Hx**

• IV use**

• Overdose Hx*

• Suicide Hx*

• Incarceration Hx**

• Cocaine use**

• Alcohol use**

• Benzodiazepine use**

Not Significant• Education• Veterans• Marijuana use• Xanax use• Klonopin use• Valium use

*p<.01 **p<.001

Predictors of Heroin/No Heroin in Blood• Performed logistic regression• 10 factor model significant predictor

– (χ2(df=7) = 287.92, ρ < .001, R2 = 22%-30%)

Factor b ρ βGender -0.56 .001 0.57Medical History -0.53 .001 0.59Mental Health -0.61 .001 0.55Substance Misuse 1.04 .001 2.83IV Use 1.50 .001 4.47Previous Overdose -0.43 .05 0.65Recent Incarceration 0.54 .05 1.71Cocaine Use 0.47 .01 1.60Alcohol Use 0.56 .001 1.76Race 0.73 .001 2.07

Reference group = No heroin in blood

Summary of Predictors• People who died with no heroin in their blood were

more likely:– Female– Have a medical and a mental health history– Had a previous overdose

• People who died with heroin in their blood were more likely:– Not white– History of substance misuse and IV use– Recent release from incarceration or inpatient– Use cocaine and alcohol

Final Thoughts

• Dealing with two different populations• Prevention and intervention efforts not

universal• Need specific and targeted efforts to address

unique characteristics of at-risk populations

THANK YOU!

QUESTIONS

Preventing HeroinInitiation and Deaths

Presenters:• Bennett Allen, MA, Research Associate, New York City Department

of Health and Mental Hygiene• Alex Harocopos, MS, Senior Research Associate, New York City

Department of Health and Mental Hygiene• Aaron Willis, AM, LSW, PhD Candidate, Indiana University School

of Social Work

Heroin Track

Moderator: Grant T. Baldwin, PhD, MPH, Director, Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, CDC, and Member, Rx and Heroin Summit National Advisory Board

rx16 heroin tues_200_1_allen-harocopos_2willis

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