SUBSTANCE ABUSE TRENDS

1. SUBSTANCE ABUSE TRENDS THE AVISA GROUP SEPTEMBER 2005

2. DATA AND INFORMATION ON PRESCRIPTION DRUGS AND TRENDS IN SUBSTANCE ABUSE • HEROIN • OTHER NARCOTICS • OXYCONTIN® • VICODIN® • METHADONE • BUPRENORPHINE • METHADONE IN CALIFORNIA THE AVISA GROUP

3. HEROIN • Heroin is widely available in the United States. In 2004, the National Survey on Drug Use and Health (NSDUH) estimated that 398,000 Americans used heroin in the previous 12 months[1]. However, it is difficult to obtain an accurate measure of use because of the transient nature of much of the heroin using population. The Office of National Drug Control Policy estimates that there are between 750,000 and 1,000,000[2]. • These varying estimates of use imply that evidence from trends or comparisons across geographic areas derived from the same sources will be useful information, but that precise estimates of the absolute prevalence must be used with caution. • Use of heroin in the United States has varied over time. In general terms, use rates were high in the 1970’s, fell to a lower level and remained at that level in the 1980’s and early 1990’s, rose in the second half of the 1990’s, and appear to have declined some since 2000, although not to the use rates that were characteristic of the 1980’s. THE AVISA GROUP

4. HEROIN – TRENDS IN ANNUAL PREVALENCE OF USE • A data series from Monitoring the Future[3] provides the best available measures of the prevalence of heroin abuse over time in the United States. The results of their surveys, which started in 1976, are shown below. Note, that the surveys began with 18 year olds only, and then progressively added older age groups over time. THE AVISA GROUP

5. HEROIN – USE AMONG ARRESTEES • The percentage of arrestees who test positive for opiates, predominantly heroin, has remained steady since 2000[4]. THE AVISA GROUP

6. HEROIN – GEOGRAPHIC DIFFERENCES IN USE • Opiate addiction is best understood within a REGIONAL framework. Substances and patterns of abuse have unique regional characteristics. • Use of Heroin varies by geographic area of the United States. The Community Epidemiology Work Group reported in 2005 that “In 2003 – 2004, heroin abuse indicators were stable or mixed in 15 CEWG areas, but high in Midwest and Northeast areas. Heroin indicators decreased in five areas (Denver, Honolulu, San Diego, San Francisco, and Seattle) located in the western half of the nation, and increased only in Washington, DC”[5]. • The percentage of arrestees who test positive for opiates varies greatly by geography. The following are the percentages in 2003 for some regions of interest to CRC: • Indianapolis, IN 5.1% • Los Angeles, CA 2.0% • Portland, OR 15.0% • Sacramento, CA 6.9% • San Diego, CA 5.1% • The following Chart shows use rates among twelfth graders since 1976. The South and the West are generally lower in use rates than the Northeast and North Central regions. THE AVISA GROUP

7. INFORMATION FROM AVISA INFORMANTS ON REGIONAL TRENDS IN HEROIN ABUSE • There is no perceived decline in the incidence and prevalence of heroin abuse in the Northeast corridor. Demand remains high and may be slightly increasing, according to law enforcement contacts throughout the region. • Highly pure (> 50%) “China white” heroin is widely available throughout the Northeast corridor. This type of heroin can be abused through “snorting,” smoking, or injection. • Retail prices are stable but the “cost per high” is decreasing, because of the increasing purity of the drug available on the street in the Northeast. • There is little perceived cross-over abuse of OxyContin by street heroin addicts in the Northeast. (“OxyContin® is not a problem for us…there’s too much good quality heroin on the street…”…John Galea, Director of the Street Studies Unit of the New York Office of Alcohol and Substance Abuse Services. • There is little to no heroin abuse evident in Appalachia. The prevailing explanation for this fact is that retail heroin distribution is largely controlled by urban, African-American criminal gangs with few to non-existent contacts in the Appalachian region. • Opiate abuse appears to be stable or even slightly increasing in California over the last few years. Demand for street heroin appears to be stable in California and slightly decreased in the Pacific Northwest. Demand for prescription opiates, either through “legal” MD prescriptions or diversion, is increasing significantly throughout the region. There is no decline in opiate abuse detectable from other non-treatment data bases (mortality and morbidity, law enforcement, etc.) • “Black tar” heroin from Mexico is the predominant form of heroin available throughout the West region. It is widely available, with wholesale prices down over the past few years and purity increasing. However, even with recent increases in purity, most heroin available in the region is only 20-25% pure (compared to > 50 % in the East). THE AVISA GROUP

8. REGIONAL TRENDS IN HEROIN USE THE AVISA GROUP

9. OTHER NARCOTICS • Use of narcotics other than heroin has been increasing in the United States since the early 1990’s. • The Community Epidemiology Work Group, reported in January 2005 that “narcotic analgesic drug abuse indicators increased in almost all CEWG areas in 2003 – 2004 • The long term trend, from Monitoring the Future, shows use declining throughout the 1980’s but beginning a rapid increase in the mid 1990’s. Although the rate of use among 18 year olds appears to have leveled off in 2003 and 2004, a leading indicator of trends in use in the general population, it is still increasing among older age groups. • Use rates in the South and the West are generally lower than those in the Northeast and North Central regions. THE AVISA GROUP

10. OTHER NARCOTICS – USE TRENDS BY AGE CATEGORY THE AVISA GROUP

11. OTHER NARCOTICS – INFORMATION FROM AVISA INFORMANTS • Prescription opiates, obtained either “legally” through an MD’s prescription or illegally through street diversion of pharmaceutical drugs, have been and remain the opiate of choice in the Appalachian region. OxyContin® has in the past been a major drug of abuse but all other prescription opiates (Vicodin®, codeine, etc.) are also abused as available. • With the recent increases in opiate prescription abuse throughout the West region, cross-over abuse between classes of opiates is beginning to become more widespread. As opposed to the East, where heroin addicts remain largely confined to heroin use, and the Appalachian region, where opiate addicts abuse almost entirely prescription drugs (OxyContin® and increasingly methadone), in California opiate addicts appear more likely to abuse one or more class of opiates at different times. THE AVISA GROUP

12. OTHER NARCOTICS – USE TRENDS BY GEOGRAPHY THE AVISA GROUP

13. OXYCONTIN® • OxyContin® was introduced in 1995 by Purdue Pharma • OxyContin® contains the drug oxycodone in a timed-released tablet • A generic version of OxyContin® produced by Endo Pharmaceuticals was launched 06/08/2005 • Prescription data from Drug Topics shows the following trend of the number of OxyContin® prescriptions from 2000 - 2004: THE AVISA GROUP

14. OXYCONTIN® • OxyContin® is a subject of the DEA’s National Action Plan to reduce diversion and abuse of prescription drugs • DEA reports that “DEA’s National Action Plan has been successful in addressing OxyContin® diversion as evidenced by (1) a reduction in the rate of increase of OxyContin® prescriptions being written; and (2) a leveling-off of OxyContin® sales since the Plan’s implementation in the Spring of 2001”. Karen Tandy, Administrator, DEA 3/24/2004. • One key strategy that the DEA urges States to take in order to reduce the diversion of prescription drugs is a Prescription Drug Monitoring Program. Research has shown that these programs can be effective when properly implemented. A portion of the costs of these programs is supported by the DEA and the Bureau of Justice Assistance. As of August 2005, such programs exist in 26 States, including the following States where CRC has a substantial number of methadone clinics: California, Indiana, and West Virginia. • The Prescription Drug Monitoring Program in West Virginia was re-enacted in 2002[6], after having been discontinued in 1998. The reenactment followed a steep increase in the distribution of oxycodone in the State following discontinuation in 1998 and was responsible for a leveling off of the amount of oxycodone distributed in the State in 2002 and thereafter. THE AVISA GROUP

15. OxyContin® • At a January 2005 meeting convened by the National Institute on Drug Abuse (NIDA), the Community Epidemiology Work Group identified the following trends: • Oxycodone abuse indicators were identified more often than indicators for other analgesics • In Los Angeles, other opiates/synthetics continued to constitute a marginal proportion of all Los Angeles County treatment admissions • Like other drugs of abuse, the illicit use of OxyContin® varies considerably by region. The chart below, from Monitoring the Future shows a two year trend by region for use among twelfth graders, an indicator that has been shown to be predictive of future use. The data indicates use declining in the Northeast and North Central regions, increasing substantially in the South and leveling off in the West. • Avisa informants report that OxyContin® abuse continues in Appalachia but has decreased over the last two years. The perception is that this decrease is due to the efforts of law enforcement to curtail abusive prescribing practices among some of the region’s doctors. THE AVISA GROUP

16. OxyContin® THE AVISA GROUP

17. VICODIN® • Vicodin® is a form of hydrocodone bitartrate and acetaminophen supplied in tablet form for oral administration, manufactured by Abbott Laboratories. Other trade names of this combination include Anexsia®, Hycodan®, Hycomine®, Lorcet®, Lortab®, Tussionex®, Tylox®, and Vicoprofen®. • The combination of hydrocodone bitartrate and acetaminophen was the most frequently prescribed drug in the United States in 2004. • From 2000 to 2004, the number of prescriptions increased at an average annual rate of 8%. • Like other drugs of abuse, the illicit use of Vicodin® varies considerably by region. The data indicates that illicit use among twelfth graders, a leading indicator of trends in the general population, is declining in the North Central region, and leveling off in 2004 in the other regions. THE AVISA GROUP

18. METHADONE • There are two distinct markets for methadone: Narcotic Treatment Programs (“Methadone Clinics”) and retail distribution. The Drug Enforcement Administration permits the use of methadone to treat addiction to opiates to be performed ONLY by methadone clinics (with the small scale exception of certain office-based opioid treatment program pilot projects). However, physicians are permitted to prescribe methadone for other purposes, including most importantly for the alleviation of pain. The amount of methadone supplied to retail pharmacies, which is the distribution channel associated with methadone prescriptions for the treatment of pain, has been increasing rapidly (Data from the DEA; data is missing for calendar year 2000). • Methadone supplied to pharmacies for use in treatment of pain is distributed in the form of tablets; methadone supplied to NTPs is distributed in the form of powder that is mixed as a liquid for administration to clients. THE AVISA GROUP

19. RETAIL SHIPMENTS OF METHADONE THE AVISA GROUP

20. METHADONE • Anecdotal reports from the West region of the United States suggest that prescription methadone, in the form of tablets, is sufficiently inexpensive on the street that some potential clients of methadone clinics find the drug is cheaper to purchase on the street than it is to obtain from a methadone clinic. • Data from the DEA show that the quantity of methadone supplied through the retail distribution system is approaching the quantity supplied to methadone clinics. By the end of 2004, in the South and West, retail distribution exceeded and in the Northeast equaled the quantity supplied to methadone clinics. The Northeast is the only region where the quantity of methadone supplied to the retail channel is below the quantity supplied to NTPs. • The flattening of the trend line of methadone shipments to NTPs beginning in the last quarter of 2003 on a national basis may be due, in part, to the ongoing increase in the distribution of methadone through the retail channel. The Northeast region of the US is the only region where retail shipments of methadone are significantly below shipments of methadone to NTPs, and is also the only region where shipments of methadone to NTPs and is also the region that was experiencing the most rapid growth in shipments to NTPs during the second half of 2004. THE AVISA GROUP

21. SHIPMENTS OF METHADONE TO NTPS AND RETAIL SETTINGS THE AVISA GROUP

22. METHADONE – INFORMATION FROM AVISA INFORMANTS • There is some diversion of methadone from treatment programs to street abuse in the Northeast reported by Avisa informants, with methadone commanding a price of $1 per mg in NYC. • In Appalachia, an increase in the abuse of methadone obtained through non-OTP channels has been noted. This non-OTP methadone is obtained either from an MD’s prescription or through street diversion from pharmacies and doctors’ offices. (“Every time we do a search warrant now, we seem to find methadone…”….George Sungy, DEA Intelligence Analyst, Appalachia High Intensity Drug Trafficking Area) THE AVISA GROUP

23. BUPRENORPHINE • Buprenorphine was approved by the FDA for use in treatment of opioid abuse and dependence in October, 2002. Under the Drug Abuse and Treatment Act (DATA), physicians may request a “waiver” that permits them to prescribe buprenorphine from their offices; it may also be used by NTPs. • Shipments of buprenorphine got off to a slow start in 2003, but increased in 2004 THE AVISA GROUP

24. BUPRENORPHINE • Buprenorphine is much more expensive than methadone, with a retail price that is an average of $9 - $11 per day for the medication. The market for buprenorphine treatment is different from the market for methadone treatment of opiate abuse and dependence. Patients treated with buprenorphine are more likely to be employed, have higher income and educational levels, and are more likely to be white than are methadone patients. • To date, the introduction of buprenorphine does not appear to have had an impact on the market for methadone treatment, in large part because of the difference in patient populations for the two treatment options. THE AVISA GROUP

25. METHADONE IN CALIFORNIA AND THE WEST COAST • California often leads the rest of the country in many social trends. • In the West, shipments of methadone through the retail channel exceeded shipments to NTPs in the second quarter of 2004. THE AVISA GROUP

26. METHADONE • According to data from SAMHSA, the annual number of admissions for methadone treatment in California have been declining since 1994. THE AVISA GROUP

27. METHADONE • Our research and inquiry into the phenomenon of declining admissions for methadone treatment in California has revealed the following factors that have contributed to this decline in admissions to methadone treatment: • A portion of the increasing supply of methadone in the retail market is becoming available on the street at prices that are below those charged by methadone clinics for a treatment visit. In essence, patients can get the drug that constitutes the major component of their treatment more cheaply and with fewer requirements on the street than they can from a clinic. • Proposition 36 in California – the Substance Abuse and Crime Prevention Act – injected $100 million of new funding into the substance abuse treatment system, beginning in 2001. Some clients who prior to the implementation of SACPA were not eligible for public funding for their treatment and had to pay out of their own pocket gained access to a new source of payment for substance abuse treatment. However, the treatment under SACPA is managed by the courts in California, who have historically been hostile to methadone treatment. Therefore, SACPA may have diverted some patients away from methadone treatment beginning in 2001. • Some contacts emphasized the growing importance of a “self-treatment” use of opiates, especially methadone obtained through MD prescription outside traditional methadone treatment programs, and even diverted buprenorphine. THE AVISA GROUP

28. SOURCES OF STATISTICS • [1] Substance Abuse and Mental Health Services Administration. (2005). Overview of Findings from the 2004 National Survey on Drug Use and Health (Office of Applied Studies, NSDUH Series H-27, DHHS Publication Number SMA 05-4061). Rockville, MD • [2] Executive Office of the President, Office of National Drug Control Policy, Drug Policy Information Clearinghouse, Fact Sheet: Heroin June 2003 NCJ 197335 • [3] Johnston, L.D., O’Malley, P.M., Bachman, J.G., & Schulenberg, J.E. (2005). Monitoring the Future national results on adolescent drug use: Overview of Key Findings, 2004 (NIH Publication No. 05-5726). Bethesda, MD: National Institute on Drug Abuse • [4] US Department of Health and Human Services, National Institutes of Health, National Institute of Drug Abuse, Epidemiologic Trends in Drug Abuse: Proceedings of the Community Epidemiology Work Group, January 2005 • [5] National Opinion Research Center, Arrestee Drug Abuse Monitoring Program, Drug and Alcohol Use and Related Matters Among Arrestees 2003. • [6] GAO “Prescription Drugs: state Monitoring Programs Provide Useful tool to reduce Diversion” May 2002 GAO-02-634 THE AVISA GROUP

29. INFORMANTS – ROF OVERVIEW AND CONTRACTING • Gary Henschen M.D. • Southern Regional Medical Director, Magellan Health Services • Tom Hanline M.D. • South Central Regional Medical Director, Magellan Health Services • Bo Ciaverelli, M.D. • Mid-Eastern Regional Medical Director, Magellan Health Services • Greg Miller, M.D. • Western Region Medical Director, Magellan Health Services • Michael Glasser, M.D • Senior Medical Director, Western Region, Managed Health Network • Rowland Pearsall, M.D • Medical Director, Eastern Region, Managed Health Network • Don Fowls, M.D. • Former CEO, Schaller Anderson Behavioral Health Care • Former Senior Vice President, Value/Options Behavioral Care • Craig Coenson, M.D. • Senior Medical Director, CIGNA Behavioral Health • Karin Wilson • Director of Contact Negotiations, Managed Health Network • Lenny Peck • Director of Contracting, Value/Options THE AVISA GROUP

30. INFORMANTS – REGIONAL TRENDS • John Galea • Chief of Street Research Unit, New York Office of Alcohol and Substance Abuse Services • New York Community Epidemiology Work Group • Thomas Carr • Director, Washington-Baltimore High Intensity Drug Traffic Area • Michael Lancaster. M.D. • Chief of Clinical Policy, Division of Mental Health, State of North Carolina • George Sungy • Intelligence Analyst, Drug Enforcement Agency, Appalachia High Intensity Drug Traffic Area • Erin Artigiani • Deputy Director of Policy, Center for Substance Abuse Research, University of Maryland • Baltimore/Washington Community Epidemiology Work Group • Beth Rutkowski • Epidemiologist, UCLA Research Center for Integrated Substance Abuse Programs • Los Angeles Community Epidemiology Work Group • Rudy Lovia • Intelligence Analyst, Los Angeles Clearinghouse • Caleb Banta-Greene • Seattle Community Epidemiology Work Group THE AVISA GROUP