Drug Trends in St Louis - University Of Maryland
Drug Abuse Trends in St. Louis: 2014 Update
Heidi Israel PhD, FNP
Heroin use was present throughout the region in 2014, yet indicators have stabilized. Treatment slots and deaths related to use are still at high levels but the leveling off in indicators may be related to aggressive grass roots efforts, the increased use and availability of naloxone by first responders, and DEA and local law enforcement efforts to stem availability. Other opiates, including prescription narcotic abuse and illicit fentanyl, continue to be areas where more focus is needed. Methamphetamine continues to climb, particularly in areas outside of St Louis City and County. The ongoing discussion on substituted cathinones and other synthetic cannabinoids is an area requiring monitoring and new ways to quantify their use.
Data Sources
This report analyzes trends in substance abuse in St Louis area based on the most recent data, calendar year 2014, obtained from the following sources:
Mortality data- on drug related and accidental overdoses due to drug toxicity are from the St Louis City and County Medical Examiner's (ME) office and outlying counties where the St Louis ME reports the decedents cause of death. Accidental overdose includes cases where drug toxicity or mixture of drug toxicity significantly contributed to the cause of death.
Addiction treatment data- This data is from the state of Missouri Department of Mental Health, Division of Behavioral Health and includes detailed information on state supported treatment admissions in St Louis City and County and overview drug admission information for the 4 regions of the state for specific drugs.
Drug seizure and purity information ? is received from the U.S. Drug Enforcement Administration.
Poison Center data on exposures and calls regarding various substances as reported to the local Poison Control system.
Heroin and other opiates
Heroin use, purity, and availability have stabilized regionally, including rural and suburban areas surrounding St. Louis. St. Louis is a destination market and is subject to all the changes that occur in the supply chain. That being said, supply has continued to be easily accessible. A recent large heroin bust in 2015 will test the hypothesis on ease of availability in the next reporting year.
Heroin was stable at high levels in the St. Louis area in all indicators in 2014 (exhibit 1). Heroin availability and purity began to climb in late 2008. Prior to that increase in availability and purity, heroin was found among small pockets of injection drug users (IDUs). With this
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Drug Trends in St Louis 2014
increase in deaths and spreading use, many communities became alarmed. Grassroots public awareness efforts may be responsible for an effect with the young potential new user. Access to heroin is reported in St Louis County schools, phenomena not seen until 2011. It is a frequently discussed topic and anecdotal media coverage reports heroin availability throughout the region.
In 2014, 37.6 percent or 4,727 (of a total 12, 567) treatment admissions reported heroin as the primary substance of abuse, compared with only 13.2 percent in 2007 (approximately 1,458 of just under 1,000 treatment admissions) (Exhibit 1). In 2013, there were 4,465 of 13,008 admissions for heroin. Interestingly, total state treatment capacity has not risen dramatically in the last 10 years. Heroin indicators surpassed alcohol and marijuana indicators in treatment admissions data beginning in 2011. Heroin remained the most frequently reported drug on admission in state supported treatment in 2014. Anecdotal reports indicate that it is also frequently reported in private treatment admissions. Outlying areas of Missouri have relatively low admissions for heroin (Exhibit 2).
Two types of heroin continued to be available in the area and remained pure and inexpensive. Heroin treatment admissions in 2014 (Exhibit 5) represented 37.6 percent of all admissions; this proportion exceeded those for alcohol admissions, which historically represented the highest percentage of admissions. This trending upward of heroin admissions began in 2006, and became the number one reported drug in 2012. In 2013 and 2014, over 60 percent of heroin treatment admissions were younger than 35, but, on a positive note, clients less than 25 decreased slightly from 19.8 percent in 2013 to 17.4 percent in 2014 (Exhibit 1).
Admissions to some available treatment depended on ability to pay. Some heroin abusers in need of treatment utilized private pay methadone programs. Buprenorphine is a treatment option at private centers, but it is expensive. Some younger users were reporting initial addiction to prescription pain pills prior to starting to use heroin. Of the methods of administration, 64.5 percent of heroin treatment clients reported injection use, a slight increase over 66.7 percent in 2013 (Exhibit 1). This trending back to injection has not coincided with lower purity, but widespread experimentation in the use of the drug. The stability in deaths, increase in treatment admissions, and consistently high purity of heroin presents a stable, if not saturated, picture of heroin currently. Among heroin treatment admissions, males accounted for 59.6 percent, while females represented 40.4 percent. Cocaine and marijuana were the most frequently cited secondary and tertiary drugs of abuse for heroin treatment clients.
Both the DEA and DMP made buys in the area. Purities of 25-55 percent have been reported for the off-white or tan powdered heroin. Additional heroin in St Louis has not been identified as to its origin (signature) and was assumed to be Mexican. The consistently higher purity heroin in St. Louis has allowed for expansion into a larger market with inexperienced users. Most heroin was purchased in a capsule (one-tenth-gram packages of heroin) for $10?$20 or as one-half-gram baggies that sold for $100 each (exhibit 2). Quetiapine (Seroquel?) has been identified as a cutting agent in many samples, as well as the standard cutting agents typically used (such as diphenhydramine). Fentanyl has also been noted with heroin and is discussed later.
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Drug Trends in St Louis 2014
The ME data report for 2014 showed a slight down tick in heroin-related deaths in an area covering St. Louis City and St. Louis County and rural counties of Franklin, Jefferson, and St. Charles. The ME identified 217 heroin-related deaths, down from 310 in 2011. (Exhibit 3) Of these deaths, 35.4 percent were younger than 30; 71.4 percent were Caucasian. There were 67 deaths in the city and 108 heroin-related deaths in St Louis County. Of the total heroin deaths, 42 were reported from Jefferson, Franklin, and St. Charles Counties. Even with the decreased availability of cocaine outside of the city, a small percentage of these deaths represented use of heroin and cocaine together, many times also mixed with alcohol.
Other opiates represented 3.6 percent (or 474) of all treatment admissions in 2014. These admissions for abuse of other opiates seem to represent a slight increase in treatment admissions, but this may be under-represented by the lack of treatment availability. Prescription opiates are believed to be linked to the introduction of younger users to the effects of opiates, possibly assisting in the fueling of heroin use by a wide range of users. No pharmacy database exists in Missouri to monitor these prescriptions. These abusers were diverse: young users recreationally getting high, chronic pain medication abusers, and more recently, discussions of polydrug geriatric abusers.
Hydrocodone and oxycodone were the two most frequently identified opiates other than heroin detected in drug items seized and analyzed by NFLIS laboratories in the St. Louis MSA in 2014. Of the NFLIS items seized, oxycodone and hydrocodone represented 6.2% of these items (Exhibit 4).
OxyContin? (a long-lasting, time-release version of oxycodone) abuse remained a concern for treatment providers and law enforcement officials and was seen in emergency departments by patients requesting refills. Many emergency rooms have adopted restricted refill policies for narcotics to prevent abuse. Abuse of oxycodone remained a concern in medical settings, where the drug is preferentially sought. The use of hydromorphone remained common among a small population of White chronic addicts, based on anecdotal information (Exhibit 2). New extended release narcotics will complicate the prescription drug abuse picture.
Fentanyl, methadone, oxycodone, and hydrocodone continued to be reported in ME and treatment admissions data. Heightened availability of prescription narcotic analgesics were reported in the more rural areas of the metropolitan statistical area (MSA). Fentanyl was found in combination with heroin in ME data, and occasionally alone in decedents that also were using cocaine or methamphetamine, which may indicate that they expected to use heroin in conjunction with these drugs. This mixture of fentanyl and heroin suggests that it may possibly be done at the seller level.
Fentanyl was identified in 27 deaths in St. Louis City and County and the 4 targeted rural counties (St. Charles, Jefferson, Franklin, and St Francois) in 2014. l. Methadone abuse again was seen in ME data. Methadone overdoses were reported 18 cases. The use of illicit methadone versus prescription methadone remained difficult to establish.
Cocaine
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Drug Trends in St Louis 2014
While the DEA's emphasis in the St. Louis area has shifted from cocaine to methamphetamine and heroin, reports from law enforcement sources, the DEA, and street informants indicated consistent quality and availability of cocaine (Exhibit 2). Because cocaine and heroin were used together in the past, the presence of heroin and methamphetamine in some drug related deaths suggests that users may have believed they were using cocaine with heroin instead. No new information was available on pricing and purity of cocaine in Kansas City and smaller cities outside St. Louis.
Cocaine treatment admissions declined markedly in recent years. In 2014, only 5.7 percent or 712 treatment admissions reported cocaine as the primary substance problem, compared with 22.8 percent (or 2,250 admissions) in 2007 (Exhibit 1). Most primary cocaine treatment clients (86 percent) reported smoking crack cocaine. A decrease in the use of combined cocaine and heroin ("speedball") by injection drug users (IDUs) has been noted.
Cocaine was reported as the fourth primary drug of abuse among all treatment admissions in 2014, following heroin, alcohol, and marijuana. This represents a change for the region over the past 7 years, as the numbers of primary cocaine admissions have decreased. Of these cocaine treatment clients, 85.9 percent were older than 35. Marijuana, heroin, and alcohol were the most frequently cited secondary and tertiary drugs of abuse among primary cocaine admissions.
NFLIS data indicated that 8.9 percent of the drug items seized for the St. Louis MSA contained cocaine in 2014. This placed cocaine as the fourth most frequently identified substance in the NFLIS system during 2014 (Exhibit 4).
The ME data report for 2014 for the St. Louis area showed that cocaine-involved deaths showed a small uptick compared to 2012 and 2013. Deaths declined from 167 in 2007 to 64 in 2014 (Exhibit 1). Some deaths in older cocaine users were associated with cardiovascular catastrophic incidents such as aneurysm or intracranial hemorrhage. Cocaine was the drug identified in three of four stillborn infants in the ME data.
Methamphetamine
Methamphetamine indicators remained elevated in cities and rural areas other than St. Louis City and County in 2014.The distribution networks are believed to be different for methamphetamine, unlike cocaine and heroin, which has led to increased availability throughout the region. Clandestine laboratories, which account for a small amount of the methamphetamine available in Missouri, decreased statewide to 1,045 in 2014 from 1,985 in 2012. Jefferson County, 20 miles outside of St Louis, reported 205 incidents for 2014, the highest of any county in Missouri
Methamphetamine ("crystal" or "speed"), along with alcohol, remained a primary drug of abuse in both the outlying rural areas and statewide. Most of Missouri, outside of St. Louis and Kansas City, is rural. Methamphetamine continued to be identified as a problem in rural communities. The drug appeared regularly in treatment data in rural areas, and methamphetamine has been identified as a problem in all parts of the State (Exhibit 2).
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Drug Trends in St Louis 2014
Primary treatment admissions for methamphetamine in 2014 in St. Louis represented 4.1 percent or 514 of total admissions (Exhibit 1). While the treatment admissions have increased gradually over the past few years in St Louis, methamphetamine is available and used at higher levels in other parts of the State. Marijuana and alcohol and some heroin were the most frequently cited secondary and tertiary drugs of abuse among these clients. Clients entering treatment were typically self-referred. Methamphetamine use increased in both the Southwest and Southeast regions of Missouri (Exhibit 2), with a net increase of more than 10% in the Southeast region (1300 admissions in 2014, up from 1173 in 2013) and Southwest region (.2,170 admissions in 2014, up from 1,936 admission in 2013).
Hispanic traffickers were the predominant methamphetamine distributors in St. Louis. Shipments from "super laboratories" in the Southwest were trucked in on the interstate highway system. This network contrasts with the local "mom and pop" laboratories that fueled much of the methamphetamine debate in the State over the past 10 years. The purity of the methamphetamine obtained through this source has improved in recent years. Crystallized methamphetamine was available in Kansas City and outlying areas of the State, with some availability in St. Louis. Because methamphetamine is so inexpensive and appeals to a wide audience, it is likely that its use will continue, particularly in rural Missouri.
NFLIS data for 2014 showed methamphetamine among 11.5 percent of drug reports among drug items seized and analyzed, ranking third. This reflects an increase over both 2013 and 2012. Pseudoephedrine legislation has had an impact on the ease of producing clandestine methamphetamine. NFLIS reported 1.0 percent of total reports were pseudoephedrine among seized drug items analyzed during this period (Exhibit 4).
Of the 38 deaths involving methamphetamine in 2014, almost half were in Jefferson County. The number of reported methamphetamine related deaths in the region in 2012 and 2013 was 27 deaths (Exhibit 3).
Marijuana
Marijuana admissions in 2014 (n=2,173) accounted for 16.9 percent of all admissions in the St. Louis region. Many factors may account for the continual decrease of marijuana admissions from 2,836 in 2008 including heroin prevalence and treatment slot availability (Exhibit 1). Marijuana, viewed by young adults as acceptable to use, was often combined with alcohol. Some prevention organizations reported resurgence in marijuana popularity, and a recent decrease in penalties in St. Louis City brought opposition from prevention organizations. The 25-and-younger age group accounted for 52.9 percent of primary marijuana treatment admissions in 2014. The 12?17 age group entering treatment represented 28.2 percent of treatment admissions in 2014. Increased THC (tetrahydrocannabinol) content of marijuana should not be ignored as a component of voluntary admissions.
Marijuana was available from Mexico or domestic indoor growing operations. The going rate for an "eighth" (about 3.5 grams) was $60. Marijuana prices in Illinois were similar. The Highway Patrol Pipeline Program monitors the transportation of all types of drugs on interstate highways. Much of the marijuana grown in Missouri is shipped out of the State. Marijuana remains the most
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