Contents

This Advance Report is a synthesis of findings presented at the 52nd semiannual meeting of the Community Epidemiology Work Group (CEWG) held in Philadelphia, Pennsylvania, on June 11-14, 2002. Sponsored by the National Institutes of Health, National Institute on Drug Abuse, the CEWG is a network of epidemiologists and researchers in the United States that meets twice a year to review current and emerging substance abuse problems. The members present drug abuse indicator data, survey findings, and other quantitative information compiled from local, city, State, and Federal sources. To assess drug abuse patterns and trends, data from a variety of health and other drug abuse indicator sources are accessed and analyzed. Sources include public health agencies, medical and treatment facilities, medical examiners' and coroners' offices, criminal justice and correctional offices, law enforcement agencies, poison control centers, and sources unique to local areas.

National data are used to enhance what is presented by CEWG members. Large-scale Federal databases used in analyses include the Treatment Episode Data Set and the Drug Abuse Warning Network (DAWN) data on emergency department (ED) drug-related mentions and medical examiner (ME) drug abuse-related deaths, all sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA); the Arrestee Drug Abuse Monitoring (ADAM) program funded by the National Institute of Justice (NIJ); the Domestic Monitor Program (DMP), the System to Retrieve Information on Drug Evidence (STRIDE), and other information on drug seizures, price, and purity from the Drug Enforcement Administration (DEA); drug seizure data from the United States Customs Service; and arrestee data from the Uniform Crime Reports maintained by the Federal Bureau of Investigation.

Drug abuse is a complex, dynamic, and constantly changing phenomenon requiring constant surveillance. To identify new drugs of abuse and to monitor changes in patterns, trends, and populations at risk, the CEWG uses a variety of indicators.

In reading this and other CEWG reports, the following points should be considered:

• While alcohol and tobacco remain the most widely abused substances in the Nation, the focus of the CEWG is on illicit drugs of abuse.


• Drug abuse patterns not only change over time but also vary by area and by populations within areas.


• While a particular drug or drugs may dominate in a given area, a majority of drug abusers use multiple drugs (including alcohol).


• Drugs are administered in different ways, resulting in different effects and different health consequences.


• Illicit drugs are sold in different forms and at different purity levels, factors that have immediate and long-term health consequences.


• Depending on the sources used, different data may not be comparable across geographic areas.

The CEWG areas include:

Information reported at each CEWG meeting is distributed to drug abuse prevention and treatment agencies, public health officials, researchers, and policymakers. The information is intended to alert authorities at the local, State, regional, and national levels, and the general public, to the current conditions and potential problems so that appropriate and timely action can be taken. Researchers also use this information to develop research hypotheses that might explain social, behavioral, and biological issues related to drug abuse.

At the June meeting, CEWG members presented information on recent drug abuse patterns and trends in their areas. A DEA official described two heroin indicator programs established by DEA's Intelligence Division--the Domestic Monitor Program and the Heroin Signature Program. Researchers from the Philadelphia area presented findings from local studies on patterns of substance abuse among the homeless and among criminal justice clients; on hepatitis C among injection drug users; on the human immunodeficiency virus (HIV) in eight local neighborhoods; and on creating a comprehensive HIV service system in a managed care environment. Also, a panel of researchers presented findings on the effects of the September 11, 2001, terrorist attacks on drug abuse in New York City, Philadelphia, and Washington, D.C.

In addition to ongoing assessment of drug patterns and trends in the United States, the CEWG provides a forum for the discussion of drug patterns and trends in other areas and regions of the world. This meeting included presentations on drug abuse surveillance and other research in Canada, Israel and Palestine, Mexico, and South Africa.

Drug Abuse Highlights for the United States

Major findings from the CEWG 2000-2001 reporting period are as follows:

Cocaine/Crack indicators remained high, with a possible resurgence in Boston, increases in Miami and New York, and decreases or stabilization in other CEWG areas (see pages 6-10).

Heroin indicators increased in Atlanta, Miami, Minneapolis, New Orleans, New York, Newark, and Philadelphia and remained high in areas such as Boston, Baltimore, and San Francisco (see pages 10-15).

Narcotic Analgesics indicators, especially for those containing hydrocodone and oxycodone, continue to rise. DAWN death mentions involving narcotic analgesics alone or in combination peaked in 16 CEWG areas, and, in 8, exceeded the death mentions for cocaine and heroin (see pages 16-20).

Marijuana indicators increased in Chicago, Hawaii, Minneapolis, New York, Philadelphia, Phoenix, St. Louis, and San Francisco, but leveled off in other CEWG areas (see pages 20-23).

Methamphetamine indicators continue to remain at elevated levels in Hawaiian, West Coast, and Southwest CEWG areas. High proportions of adult female arrestees tested methamphetamine-positive in Honolulu, San Diego, and Phoenix (45, 36, and 29 percent, respectively). Rates of DAWN ED methamphetamine mentions per 100,000 population were highest in San Francisco (14) and San Diego (13) (see pages 24-28).

MDMA (methylenedioxymethamphetamine or "ecstasy") indicators continue to rise in most CEWG areas and to spread beyond the young White populations frequenting "raves." Past-year use by 12th-graders rose from 3.6 percent in 1998 to 9.2 percent in 2001 in the most recent Monitoring the Future (MTF) Study, and large percentage increases in lifetime use are estimated from National Household Survey on Drug Abuse data, bringing the total in 2000 for lifetime use to 6.4 million Americans. Several CEWG sites continue to report that ecstasy often contains drugs other than MDMA (see pages 28-33).

Cocaine/Crack

In most CEWG areas, cocaine/crack indicators have been trending down for the past several years. In 2000-2001, indicators remained stable or mixed in 10 CEWG areas, decreased in 8, and increased in 2, with Boston reporting a "possible resurgence." Nevertheless, indicators remained high. Recent DAWN ED estimates (subject to revision) show that rates of cocaine/crack ED mentions per 100,000 population exceeded those for heroin in 16 CEWG areas. Primary cocaine/crack treatment admissions also predominated in most CEWG areas (excluding alcohol admissions). Higher percentages of adult arrestees in the ADAM program tended to test positive for cocaine than for other drugs.

Increases in cocaine/crack indicators were reported in the following CEWG areas:

Miami South Florida cocaine abuse rates continue to be among the highest in the Nation, as indicated by emergency department visits, crime lab data, and drug abuse treatment admissions.

New York Cocaine trends, which had been declining, are beginning to show increases, and the drug still accounts for major problems in New York City.

Preliminary DAWN data from the first half of 2001 continue to show the predominance of cocaine/crack mentions in hospital EDs. Rates of DAWN ED mentions per 100,000 population were higher than those for heroin in all CEWG areas except Baltimore, Newark, and San Francisco, and they clearly exceeded those for marijuana and methamphetamine in the 19 CEWG areas for which estimates could be made in the first half of 2001.

The preliminary population-based rates of cocaine DAWN ED mentions in the first half of 2001 are depicted by CEWG area in exhibit 1. As shown, the rates were highest in Chicago (125 mentions per 100,000 population) and Philadelphia (118), and lowest in Minneapolis/St. Paul and San Diego (16 each). Compared with data for the first half of 2000, Boston had a significant increase in cocaine/crack mentions in 2001, while Dallas, Denver, New Orleans, and San Diego had significant decreases.

Exhibit 2 depicts recent annual trends in cocaine ED mentions per 100,000 population in CEWG areas. Statistical comparisons between 1998 and 2000, and between 1999 and 2000, show significant declines in cocaine ED rates in Baltimore, New Orleans, Newark, and Washington, D.C., and significant increases in Los Angeles, Miami, and Seattle. The percentage changes between 1999 and 2000 also show significant increases in cocaine ED rates per 100,000 population in Atlanta, Boston, and Chicago.

Exhibit 1. Rates of Cocaine ED Mentions Per 100,000 Population by CEWG Area: First Half of 2001¹

1 Estimates for 2001 are preliminary; data were not sufficiently complete to produce 1H-2001 estimates for Atlanta. SOURCE: Adapted from DAWN, Office of Applied Studies, SAMHSA

Exhibit 2. Trends in Rates of Cocaine ED Mentions Per 100,000 Population in CEWG Areas by Year¹: 1998-2000

Excluding treatment admissions whose primary drug of abuse was alcohol, admissions for primary abuse of cocaine/crack in 2001 were highest in Atlanta (69.9 percent), followed by St. Louis (44.3 percent), Washington, D.C. (42.0 percent), New Orleans (40.0 percent), Philadelphia (39.6 percent), Detroit (38.7 percent), New York (27.9 percent), and Minneapolis (26.6 percent). Statewide, primary cocaine/crack admissions (excluding alcohol) were high in Texas (39.0 percent) and Illinois (31.6 percent).

Data from 12 CEWG areas reporting on route of administration indicate that the majority of primary cocaine admissions in 2001 smoked the drug (crack). As a percentage of all primary cocaine admissions, crack admissions were highest in Los Angeles, Minneapolis, Philadelphia, and St. Louis, ranging from 81.6 to 87.5 percent. The lowest proportions of crack admissions in the cocaine group were in Seattle (55.0 percent) and the State of Colorado (57.9 percent). Intranasal use among cocaine admissions was highest in New York (32.0 percent), Newark (28.5 percent), and Colorado (25.8 percent). In Seattle, 23 percent of the admissions group injected cocaine.

ADAM adult male and female arrestee testing data for 2000 and 2001 are presented in exhibit 3. The 2001 data are preliminary. Also, because of methodological differences in the study by gender, no gender comparisons are made. The male samples are based on probability sampling, and percentages represent weighted data. In contrast, the female samples are based on convenience sampling and different data collection methods; the unweighted percentages represent much smaller sample sizes than those for males.

The ADAM data on adult male arrestees in 2001 show that the proportions testing positive for cocaine ranged from a low of 11.2 percent in Honolulu to 46.3 percent in New York. Chicago had the second highest percentage (45.0 percent).

ADAM adult female arrestee data, available only for the first half of 2001, show especially high proportions of women testing positive for cocaine in Philadelphia (80.0 percent) and Chicago (66.7 percent), followed by New York (60.8 percent) and Denver (46.5 percent).

In Washington, D.C., 33 percent of the adult arrestees tested by the District of Columbia Pretrial Services Agency in the first quarter of 2002 were cocaine-positive.

Exhibit 3. Percentages of Adult Arrestees Testing Cocaine-Positive by Gender and Site: 2000-2001¹

Heroin

Heroin indicators remained high overall in many CEWG areas, increasing in 8, remaining stable or mixed in 11, and decreasing in 2. DAWN heroin ED rates per 100,000 population in Baltimore, Newark, and San Francisco exceeded those in other CEWG areas for all major drugs. Primary heroin treatment admissions continued to be especially high in eight CEWG areas.

Concerns about heroin abuse are illustrated below, with Miami, Minneapolis, and Philadelphia citing rises in heroin-related deaths reported by local MEs.

Chicago Emergency department mentions, treatment admissions, and population-based survey data show a continued increase in heroin use in Chicago during 2001.

Miami ED mentions and heroin-related deaths continue to rise in South Florida.

Minneapolis Opiate-related deaths, most from accidental heroin overdose, continued upward trends that began in 2000, driven by an unprecedented steady supply of high-purity low-cost heroin.

New York Heroin trends, which had appeared to be mixed, all showed signs of increasing.

Philadelphia For the fifth consecutive half-year, heroin/morphine detections in decedents exceeded cocaine detections.

Preliminary DAWN ED data for the first half of 2001 show that rates of heroin mentions per 100,000 population ranged from a low of 5 in Minneapolis/St. Paul to a high of 105 in Baltimore (exhibit 4). A comparison of the first halves of 2000 and 2001 show statistically significant decreases in heroin ED rates in five CEWG areas: Los Angeles, New Orleans, San Diego, San Francisco, and Seattle. Significant increases occurred in Miami and Minneapolis/St. Paul.

From 1998 to 2000, significant changes occurred in the rates of heroin ED mentions per 100,000 population in several CEWG areas (exhibit 5). Between 1998 and 2000, and from 1999 to 2000, heroin ED rates increased significantly in Boston, Chicago, Miami, Minneapolis/St. Paul, and New Orleans, while decreasing significantly only in Baltimore. Between 1999 and 2000, heroin ED rates also increased significantly in Atlanta and Detroit, while decreasing in San Francisco.

Exhibit 4. Rates of Heroin ED Mentions Per 100,000 Population by CEWG Area: First Half of 2001¹

1 Estimates for 2001 are preliminary; data were not sufficiently complete to produce 1H-2001 estimates for Atlanta. SOURCE: Adapted from DAWN, Office of Applied Studies, SAMHSA

Exhibit 5. Trends in Rates of Heroin ED Mentions Per 100,000 Population in CEWG Areas by Year¹: 1998-2000

Excluding alcohol admissions, the proportions of treatment admissions for primary heroin abuse were particularly high in Newark (85.6 percent), Boston (74.1 percent), San Francisco (63.0 percent), and Baltimore (60.0 percent), and ranged between approximately 42.0 and 47.0 percent in Detroit, Los Angeles, New York, and Washington, D.C.

In the 12 CEWG areas that reported on route of drug administration, injection among heroin treatment admissions predominated in 8. The proportions of heroin admissions who injected the drug were highest in Seattle (96 percent) and in Los Angeles and the State of Texas (each 89 percent). Intranasal use among heroin admissions was highest in Newark (76.5 percent), the State of Illinois (68.0 percent), New York (60.0 percent), Baltimore (47.5 percent), and Minneapolis (42.7 percent). Only Boston reported a substantial proportion of heroin smokers (29 percent).

The preliminary 2001 ADAM data on adult males show increases in opiate-positive tests in four CEWG areas, decreases in three, and little change in six, when compared to full-year data for 2000 (exhibit 6). The percentages testing positive for opiates in 2001 were highest in Chicago (24.0 percent), New York (17.7 percent) and New Orleans (15.3 percent).

Exhibit 6. Percentages of Adult Arrestees Testing Opiate-Positive by Gender and Site: 2000-2001

Exhibit 7. Domestic Monitor Program - Average Heroin Purity in 20 CEWG Areas: First Half of 2001

SOURCE: DMP, DEA

ADAM data on adult female arrestees for the first half of 2001 show that Philadelphia, at 30 percent, had the greatest proportion testing opiate-positive.

In Washington, D.C., 10.5 percent of the adult male arrestees tested by the District of Columbia Pretrial Services Agency in the first quarter of 2002 were opiate-positive.

Preliminary DMP data for the first half of 2001 in 20 CEWG areas show that the average purity of heroin was highest in Newark and Philadelphia (70 and 71 percent, respectively), followed by Atlanta, Boston, and New York (exhibit 7).

Other Opiates/Narcotics

The most recent indicators for opiates/narcotics other than heroin point to a continued increase in use, especially in the abuse of hydrocodone and oxycodone. The number of drug abuse-related death mentions in DAWN for narcotic analgesics peaked in 16 CEWG areas and exceeded those for cocaine and heroin in 8 areas.

DAWN ED data for the coterminous United States in 2000 show that narcotic analgesics and narcotic analgesic combinations were the most frequently mentioned central nervous system agents in drug-related visits. Most often mentioned were narcotic analgesics containing hydrocodone (20,098 mentions), oxycodone (10,825), methadone (7,819), propoxyphene (5,485), codeine (5,295), and meperidine (1,085). A review of data for the first halves of 2000 and 2001 show a 44-percent increase in oxycodone/combinations mentions (from 5,437 to 7,831), and a 38-percent decrease in codeine/combinations mentions (from 2,578 to 1,593). Long-term increases in narcotic analgesics ED mentions were significant for hydrocodone/combinations (116 percent from 1994 to 2000), oxycodone/combinations (166 percent), and methadone (140 percent).

Across CEWG sites in 2000, the estimated number of ED mentions for specific narcotic analgesics/combinations varied considerably. Note, however, that large proportions of the mentions were "not otherwise specified" (NOS). Hydrocodone/combinations accounted for more mentions than any other narcotic analgesics/combinations across 12 CEWG areas. These were highest in Los Angeles (459 mentions), followed by Detroit (369), Dallas (303), Chicago (281), and Phoenix (240). CEWG areas with more than 100 hydrocodone/combinations mentions in 2000 are depicted in exhibit 8.

In four CEWG areas, oxycodone/combinations accounted for the largest number of narcotic analgesics/combinations mentions. These numbers were highest in Philadelphia (658), followed by Boston (594).

Other narcotic analgesics predominated in four CEWG areas. In Chicago, the number of ED mentions in 2000 were highest for acetaminophen-codeine (442 mentions) and methadone (307). Methadone also accounted for the highest number of narcotic analgesics mentions in New York (1,095) and Newark (141). In Washington, D.C., the 316 meperidine ED mentions outweighed the 136 oxycodone/combinations mentions shown in exhibit 8.

DAWN data on drug abuse-related deaths show increases in narcotic analgesics mentions in 19 CEWG areas from 1997 to 2000 (exhibit 9). In 2000, narcotic analgesics mentions peaked in 16 CEWG areas; however, relatively few of these mentions involved only a narcotic analgesic.

Exhibit 8. CEWG Areas with the Highest Number of Hydrocodone/Combinations and Oxycodone/Combinations ED Mentions¹: 2000

1 Represents only areas where the number of mentions exceeded 100. SOURCE: Adapted from DAWN, Office of Applied Studies, SAMHSA

Exhibit 9. Number of Narcotic Analgesics Mentions in DAWN Drug Mortality Data by Year¹ and CEWG Area: 1997-2000

Other data from the 2000 DAWN mortality system show specific narcotic analgesics that ranked among the 10 most commonly mentioned drugs in different CEWG areas:

• Hydrocodone--Los Angeles (80 mentions), Detroit (48), Dallas (25), and San Diego (22)


• Oxycodone--Philadelphia (87 mentions) and Boston (21)


• Codeine--Philadelphia (216 mentions), Los Angeles (201), Phoenix (124), Detroit (103), San Francisco (92), and Chicago (88)


• Methadone--New York (146 mentions), Phoenix (47), and Chicago (46)

Selected excerpts from CEWG papers illustrate the increasing concern about the abuse of narcotic analgesics, especially hydrocodone and oxycodone.

Atlanta Treatment staff noted a continued rise in admissions for OxyContin abuse.

Los Angeles According to local law enforcement officials, diverted pharmaceuticals, specifically OxyContin, hydrocodone, Xanax, and Valium, continue to pose a tremendous abatement challenge. There exist numerous Internet chat rooms devoted to abusers seeking to illegally obtain legitimate pharmaceuticals through the Internet.

Miami Oxycodone was the cause of more fatalities than heroin, cocaine, or any other substance reported by local medical examiners in 2001. Oxycodone and other narcotic analgesics continue to be substituted for heroin.

Minneapolis Growing abuse of OxyContin by seasoned abusers escalated, particularly in rural Minnesota. Law enforcement agencies suggest that OxyContin abuse is at an epidemic level.

Philadelphia Spring 2001 focus groups reported the spread of use for oxycodone products to all racial/ethnic groups, an even split between male and female users, the youngest age of new users as 15, and oxycodone use in combination with heroin and crack. Hydrocodone mentions reported by local medical examiners have increased as well.

Phoenix ED mentions for narcotic analgesics continue to increase dramatically. In a survey of 24 Arizona methadone programs, approximately 2.5 percent of admissions were individuals addicted to OxyContin. Use of the Internet to purchase pharmaceutical controlled substances continues to be reported.

St. Louis OxyContin abuse remains a concern for treatment and law enforcement personnel. Abuse of oxycodone (Percocet and Percodan) by prescription is growing in popularity.

Seattle DAWN ED mentions show recent increases in oxycodone and hydrocodone.

Washington D.C. The illegal use of OxyContin has emerged as a substantial threat to residents of the region. Addicts use this and other pharmaceuticals to ease the symptoms of withdrawal and to heighten the effects of heroin.

Marijuana

After trending up in the 1990s, marijuana indicators are leveling off in 12 CEWG areas, and Atlanta reports a "general decline." Notable increases in marijuana indicators were reported in eight CEWG areas.

Chicago Marijuana use, alone and in combination with other drugs, appears to be increasing throughout the Chicago metropolitan area.

Honolulu Statewide, marijuana treatment admissions are the second highest in the 10 years of data recorded by the Hawaiian CEWG. Marijuana-involved deaths also increased.

Minneapolis Marijuana use among Minnesota youth has increased since 1992. Marijuana was the primary drug of abuse for one out of five people who entered addiction treatment programs in 2001; of those, one-half were younger than 18.

New York Marijuana indicators continue to reach new peaks.

Philadelphia The rate of marijuana ED mentions in Philadelphia in the first half of 2001 was the highest among CEWG cities. Focus groups reported the increased availability and use of commercial blunt wrappers made of cigar tobacco leaves as an alternative to buying cigars.

Phoenix Marijuana indicators (ED, treatment, and ADAM) have increased.

St. Louis Marijuana indicators have been trending up for some time. Primary treatment admissions more than doubled between 1997 and 2000.

San Francisco Overdose and admissions data point to an increase in marijuana prevalence.

A comparison of DAWN ED data for the first halves of 2000 and 2001 shows that rates of marijuana ED mentions per 100,000 population decreased significantly in Dallas (from 27 mentions per 100,000 population to 16), while increases were significant in Baltimore (33 to 40), Minneapolis/St. Paul (17 to a record high of 20), and Philadelphia (51 to 59).

From 1998 to 2000, several CEWG areas experienced significant increases in the rates of ED marijuana mentions per 100,000 population (exhibit 10). Between 1998 and 2000, as well as 1999 to 2000, marijuana ED rates increased significantly in Denver, Miami, Minneapolis/St. Paul, and Seattle. From 1999 to 2000, significant increases also occurred in Boston, Chicago, and San Francisco.

Exhibit 10. Trends in Rates of Cocaine ED Mentions Per 100,000 Population in CEWG Areas by Year¹: 1998-2000

Excluding alcohol, the proportions of primary marijuana treatment admissions in 2001 were highest in Minneapolis (49.2 percent) and Colorado (40.6 percent), followed by New Orleans (37.5 percent), Seattle (34.4 percent), and St. Louis (33.5 percent). Primary marijuana admissions accounted for between 19 and 29 percent of illicit drug admissions in seven other CEWG areas (Atlanta, Baltimore, Hawaii, Illinois, New York, Philadelphia, and Texas).

Available ADAM data for 2001 show that Minneapolis had the highest percentage of adult male arrestees testing positive for marijuana (54.0 percent), followed by Chicago (52.0 percent), New Orleans (46.2 percent), Detroit (45.7 percent), and Philadelphia (42.9 percent) (exhibit 11). Assuming the male data for the full year of 2001 will not differ substantially from that for partial quarters, only Phoenix will show a notable increase from 2000.

Exhibit 11. Percentages of Adult Arrestees Testing Marijuana-Positive by Gender and Site: 2000-2001

In the smaller samples of ADAM female arrestees in 2001, the highest proportions of women testing marijuana-positive were in Chicago (33.3 percent), New York (32.0 percent), and Denver (31.3 percent). The percentages for most sites do not differ substantially from those for the year 2000; the exceptions are Honolulu and Laredo, where the percentages are notably lower for the first half of 2001, and Chicago where the percentage is higher.

Methamphetamine

As in the past, methamphetamine indicators continue to be relatively high in the western part of the country. Although still relatively low, methamphetamine indicators increased in Detroit, Miami, Minneapolis, St. Louis, and Washington, D.C.

Exhibit 12. Rates of Methamphetamine ED Mentions Per 100,000 Population by CEWG Area: First Half of 2001¹

1 Estimates for 2001 are preliminary; data were not sufficiently complete to produce 1H-2001 estimates for Atlanta. 2 Dots (...) indicate that an estimate with a relative standard error greater than 50 percent has been suppressed. SOURCE: Adapted from DAWN, Office of Applied Studies, SAMHSA

Preliminary rates of DAWN ED methamphetamine/speed mentions per 100,000 population for the first half of 2001 for all CEWG areas are shown in exhibit 12. The rates of methamphetamine ED mentions were highest in San Francisco (14 per 100,000 population), San Diego (13), Los Angeles and Phoenix (8 each), and Seattle (7). A significant increase from the first half of 2000 to the first half of 2001 occurred in Miami, while significant decreases appeared for Dallas, Denver, San Diego, and Seattle.

Exhibit 13 shows trends in rates of methamphetamine ED mentions per 100,000 population from 1998 to 2000 in 10 CEWG areas where the rate in 2000 was 4 or higher. From 1998 to 2000, and from 1999 to 2000, rates of methamphetamine ED mentions increased significantly in Los Angeles, Phoenix, and Seattle. From 1999 to 2000, methamphetamine ED rates also increased significantly in Atlanta and Dallas (after decreasing significantly from 1998 to 2000) and also in San Diego.

Exhibit 13. Trends in Rates of Methamphetamine ED Mentions Per 100,000 Population in CEWG Areas by Year¹: 1998-2000

Methamphetamine-related mortality mentions appear to be low in most CEWG areas. However, MEs in Oahu and Phoenix, as well as those participating in DAWN in Los Angeles and San Diego, report increases since 1998. In Oahu, methamphetamine-related deaths rose from 35 in 2000 to 54 in 2001. In Phoenix, methamphetamine-related deaths rose from 51 in 1998 to 105 in 2000; they totaled 118 in the first 9 months of 2001. In Los Angeles, methamphetamine-related DAWN death mentions increased from 111 in 1998 to 155 in 2000, while in San Diego mentions rose from 84 to 112 over the same time period. DAWN figures for San Francisco show that methamphetamine-related death mentions rose from 45 in 1998 to 58 in 1999, only to level off to 45 in 2000.

Treatment data on methamphetamine abuse, excluding alcohol, show that the proportions of primary methamphetamine treatment admissions in 2001 were highest in Hawaii (49 percent) where crystal methamphetamine ("ice") predominates, followed by San Diego (48 percent). Excluding alcohol, methamphetamine admissions increased in Los Angeles (from 10.6 to 16.7 percent). Methamphetamine was the primary drug of abuse in 15.6 percent of the treatment admissions in Colorado and 10.6 percent in Minneapolis. Injection was the preferred route of administration in 49 percent of the methamphetamine treatment admissions in Hawaii, and nearly one-third in Colorado. Smoking was preferred in Colorado (43 percent) and Los Angeles (60 percent). Sniffing tended to be preferred in Minneapolis (42 percent), followed by smoking (31 percent).

The preliminary 2001 ADAM data on adult male arrestees show that 38.1 percent tested positive for methamphetamine in Honolulu, as did 27.3 percent in San Diego and 25.0 percent in Phoenix (exhibit 14). In CEWG areas not included in exhibit 14, the percentages of males testing methamphetamine-positive in 2001 were zero or less than 0.1 percent in three areas, and between 1.7 and 4.0 percent in another three.

ADAM data on females show high proportions testing methamphetamine-positive in Honolulu, Phoenix, and San Diego in 2001, with possible increases in Phoenix and San Diego from 2000.

Exhibit 14. Percentages of Adult Arrestees Testing Methamphetamine-Positive by Gender and Selected CEWG Areas: 2000-First to Third Quarters 2001

CEWG reports from Chicago, Detroit, and Minne-apolis indicate that seizures of methamphetamine labs are increasing. Treatment admissions for amphetamines and methamphetamine are also increasing in these CEWG areas.

Chicago The most recent data from the Illinois State Police indicate that in December 2001, more methamphetamine was seized than cocaine or heroin in nearly 50 percent of Illinois counties. Total stimulant/ methamphetamine treatment admissions in Illinois tripled to 3,771 in FY 2001.

Detroit Michigan State Police reported seizing 40 methamphetamine labs in 2000 (all outside Detroit), compared with 14 labs in 1999. During 2001, a total of 120 labs were seized by the State Police, DEA, and local police departments combinedÉ Through early June 2002, State Police seized 105 labs; at this rate, the year-end total will double that of 2001. Among statewide treatment admissions in FY 2001, there were 277 primary stimulant admissions, compared with 189 in FY 2000.

Minneapolis In 2001, there were 236 meth labs dismantled with the assistance of DEA in Minnesota, compared with 138 in 2000, 109 in 1999, and 46 in 1998. In 2002 (January through May 8), there were 98. In 2001, 4.7 percent of people entering addiction treatment programs cited methamphetamine as their primary drug, compared with 3.0 percent in 2000, and only 0.3 percent in 1991.

The Detroit CEWG member also presented information on the trafficking of chemicals used to make methamphetamine along the U.S.-Canada border. "These were imports destined for the western part of the United States."

Michigan's border with Canada has been the focus of efforts to stop the flow of large amounts of pseudoephedrine and ephedrine entering the country. The U.S. Customs Service in Detroit reported seizures of more than 10,000 kilograms of pseudoephedrine in the 6 months after September 2001, compared with 50 kilograms in the 6 months prior.

Club Drugs

The term "club drugs," as used here, includes MDMA (ecstasy); gamma hydroxybutyrate (GHB) and its precursor, gamma butyrolactone; ketamine; and flunitrazepam (Rohypnol).

The 2000 DAWN mortality data show that mentions of club drugs, while climbing, remain low in CEWG areas, compared with mentions for other drugs such as heroin and cocaine. In nearly all DAWN mortality cases involving club drugs, at least one other substance was also detected. CEWG areas with the most mentions in 2000 were Los Angeles (27 mentions), Dallas (10), and Chicago and Miami (each reporting 9).

Existing data indicate that MDMA is, by far, the most frequently used club drug. For example, the 2001 MTF study data show that, for the second consecutive year, MDMA use was more prevalent among high school students nationally than was cocaine use. From 1998 to 2001, past-year use of MDMA rose from 3.6 to 9.2 percent among 12th-graders. MTF data also showed that teens increasingly perceived MDMA as available--61.5 percent in 2000, compared with 39.0 percent in 1997.

The 2000 National Household Survey on Drug Abuse estimates indicate that 6.4 million Americans had used MDMA at least once in their lifetime. From 1995 to 2000, estimates of lifetime MDMA use among persons age 12-17 increased 130 percent, to 615,000, while lifetime use among those age 18-25 increased 318 percent to 4,014,000.

The increase in MDMA use across CEWG areas is clearly reflected in the DAWN ED data. Increases in MDMA mentions from 1998 to 2000 were significant in 11 CEWG areas for which tests could be conducted. Between 1998 and 2000, MDMA ED mentions increased significantly in 17 CEWG areas, as shown in exhibit 15. From 1999-2000, increases continued to be significant in 13 CEWG areas, with the percentage change also becoming significant in St. Louis. As is also apparent in exhibit 15, MDMA mentions peaked in 18 CEWG areas in 2000; in 8 areas, the estimated numbers exceeded 100.

Exhibit 15. Trends in MDMA ED Mentions by CEWG Area and Year¹: 1998-2000

Most CEWG areas continue to experience increases in MDMA use.

Chicago Most indicators of ecstasy and other types of club drugs continue to increase.

Detroit Seizures of ecstasy are up sharply and cases are now being reported to emergency departments in southeast Michigan.

Los Angeles Anecdotal evidence from a variety of sources lends support to the claim that use of club drugs, especially MDMA and GHB, is increasing in Los Angeles County.

Miami MDMA problems continued to increase in the first half of 2001.

Minneapolis Seizures of MDMA rose substantially at all levels of law enforcement. DEA seizures increased from 1,493 to 12,375 tablets and from 255 to 1,431 grams from 2000 to 2001.

New Orleans Club and designer drugs have shown some increase in availability and abuse. MDMA is the most prevalent and popular drug.

New York Ecstasy is widely available throughout New York City, on the street as well as at dance clubs and large social events. MDMA ED mentions increased dramatically between the first halves of 1998 and 2001, but may be stabilizing.

San Francisco The annual rate of ED mentions of MDMA more than tripled between 1999 and 2001.

Texas Ecstasy cases reported to poison control centers, treatment admissions, and State Police lab items continue to increase.

Washington D.C. Indicators show growth in MDMA use.

Several CEWG areas report that MDMA/ecstasy use continues to spread beyond young White populations in rave and dance club settings to other populations.

Atlanta The use of MDMA (or ecstasy) is being widely reported and the demographics of those using are expanding to include more African-Americans as well as older individuals.

Boston MDMA use was characterized by most contacts as still a primarily White, middle-class phenomenon, partly because of its relatively high cost. However, two sources reported that its use and distribution were increasing among non-White city youth.

Chicago Ecstasy, once limited to the rave scene, can be found in most mainstream dance clubs and many house parties, according to ethnographic reports. Street reports suggest ecstasy is widely available among high school and college students.

Los Angeles MDMA use continues to increase among high school and junior high school students. Use among Black adolescents and young adults is increasing as well. Rave promoters are beginning to target the hip-hop scene.

Philadelphia In the last 18 months, MDMA use has spread from Whites of college age and Ôtypical clubgoers in their twenties' to African-Americans and Hispanics, and from teens to people in their thirties.

Phoenix Ecstasy has become increasingly acceptable among the mainstream population. MDMA is second only to marijuana in use by all demographic groups.

The terms MDMA and ecstasy are often used interchangeably. However, ecstasy may not be pure MDMA. DEA analyses show that all tablets analyzed in 1999 and 2002 contained some MDMA. Some tablets also contained other controlled substances, such as methamphetamine and ketamine, and less than 1 percent contained noncontrolled substances, such as caffeine, ephedrine, and dextromethorphan (DXM). DEA's STRIDE analyses of ecstasy samples show that nearly 98 percent are in tablet form.

Several CEWG members reported that chemicals other than MDMA are found in pills being seized or sold as ecstasy or MDMA.

Boston State Police report that some suspected MDMA cases have turned out to be DXM or so-called Ôherbal ecstasy' containing the legal stimulant ephedra (ma huang).

Detroit Most recent samples of pills submitted as ecstasy have been found to contain various other drugs, or no identifiable drugs. Recent samples have variously contained methamphetamine, ketamine, DXM, phencyclidine (PCP), and ephedrine.

Minneapolis Laboratory analysis continues to confirm that a variety of chemical compounds other than MDMA are being sold as ecstasy.

New York Other substances are often sold as ecstasy.

Seattle The quality and consistency of MDMA remains unpredictable.

Phencyclidine

In the first half of 2001, PCP indicators increased significantly in three CEWG areas: Los Angeles, Philadelphia, and Washington, D.C. These areas, together with Chicago, also had the highest rates of PCP ED mentions per 100,000 population in the first half of 2001: eight in both Chicago and Philadelphia, five in Los Angeles, and four in Washington, D.C. The numbers of PCP ED mentions in these four CEWG areas are shown in exhibit 16.

Exhibit 16. CEWG Areas with the Highest Number of DAWN ED PCP Mentions: First Half of 2000-First Half of 2001¹

Across the coterminous United States, DAWN ED mentions of PCP increased nearly 48 percent from 1999 to 2000, from 3,663 to 5,404. The increases were significant in nine CEWG areas (exhibit 17).

Exhibit 17. Number of DAWN ED PCP Mentions in Nine CEWG Areas: 1999-2000

In 2000, there were relatively few hallucinogen-related (including PCP, lysergic acid diethylamide [LSD], and other hallucinogens) deaths reported by DAWN MEs in CEWG areas. The highest numbers of such deaths were reported in Philadelphia (33 mentions), Los Angeles (22), and Chicago and Washington, D.C. (each reporting 9).

In Washington, D.C., treatment admissions for primary PCP abuse rose 144 percent, from 43 in 2000 to 105 in 2001.

In the ADAM program in the first three quarters of 2001, 6.6 percent of the adult male arrestees in Philadelphia tested positive for PCP. This was, by far, the highest percentage of adult males testing PCP-positive in the CEWG areas included in ADAM.

Canada

The Canadian Community Epidemiology Network on Drug Use representative presented National Population Health Survey data on alcohol use among the 15 and older population. The findings indicated that 76 percent of this population were past-year drinkers--81 percent of adult men and 72 percent of women. Among youth age 15-19, 74 percent had consumed alcohol in the prior 12 months. Only 9 percent of the population were considered abstainers. Data from various sources showed a strong association between use of alcohol and illicit drugs and criminal activity. Among individuals accessing treatment in the Halifax area, alcohol continues to be the most commonly abused drug, but an increasing number of polydrug users who have concurrent mental health problems are accessing services. In the Atlantic Provinces, prescription opiates are the major drugs involved in narcotic addiction, with the main supply of injectable opiates being hydromorphone and morphine.

Israel and Palestine

Health and community officials and researchers are in the process of establishing a substance abuse monitoring system in Israel and Palestine. The system, in several respects, will be modeled after the CEWG. The system is being developed through established working relationships between Israelis, Palestinians, and international experts. Knowledge is being shared in a mutual effort to establish monitoring systems in both countries. The objective is to obtain and use information to establish policies and programs to control drug abuse. Initially, the effort has focused on drug abuse in youth populations.

Some funding for the effort was obtained from the U.S. Agency for International Development, Middle East Regional Cooperative. In Israel, the work is being coordinated by representatives of the Regional Alcohol and Drug Abuse Resources Center, Ben Gurion University. In Palestine, the work is being coordinated through the Substance Abuse and Addiction Research Center.

Mexico

Mexico's Epidemiologic Surveillance System of Addictions, a network of institutions specializing in addiction services and research, operates in 25 Mexican cities, half of which are located along the U.S.-Mexico border. The primary sources of data are governmental and nongovernmental treatment centers reporting on clients in treatment.

During 2001, data were gathered from 9,474 patients in government treatment centers (GTCs) and 17,262 patients in nongovernmental treatment centers (NGCs). In both types of facilities, cocaine was the drug most likely to be used currently (35.3 percent of GTC and 23.8 percent of NGC patients). Marijuana was the second most frequently reported current drug of abuse among GTC patients (20.4 percent) and ranked fourth among NGC patients (11.5 percent). Heroin was reported as a current drug of abuse by 23.6 percent of NGC patients but by only 2.8 percent of GTC patients. Inhalants accounted for 11.6 percent of current drug reports among GTC patients. Approximately 90 percent of patients in both types of facilities were male, and the majority used more than one drug. Marijuana (39.6 percent) and cocaine (22.3 percent) were the drugs most likely to be used among 6,688 juvenile arrestees.

South Africa

The Southern African Development Community (SADC) Regional Drug Control Programme provides support for establishment of a regional network--the SADC Epidemiology Network on Drug Use--in the 14 SADC member States. Between July 2001 and June 2002, three countries in addition to South Africa completed the first data collection phase: Lesotho, Mauritius, and the Seychelles. Botswana and Namibia began data collection in January 2002. In Lesotho and the Seychelles, alcohol and marijuana are the major substances abused, based on police and treatment data. These drugs are also prominent in Cape Town, Durban, and Gauteng, where use of Mandrax (methaqualone) is also high. Treatment demand for cocaine abuse has leveled off in Cape Town, Durban, and Gauteng, but has increased dramatically for heroin abuse in Cape Town and Gauteng.

Officials of DEA's Intelligence Division provided an overview of two programs designed primarily to detect trends in the supply of heroin in the United States--the Heroin Signature Program (HSP) and the Domestic Monitor Program (DMP). HSP provides data on heroin wholesale trafficking and distribution patterns, based on 600-900 samples annually. The samples are taken from port of entry seizures as well as randomly selected DEA seizures and purchases. DEA chemists associate the HSP samples with a heroin production process or "signature" that is indicative of a particular geographic area. The analyses provide insight into the routes and methods used to smuggle heroin into the United States.

DMP collects and analyzes data on the purity, price, and origin of retail-level heroin in 23 metropolitan areas. Undercover purchases of heroin are made quarterly (without arrests) at the retail level and are then analyzed to determine purity and the geographic source of the heroin. DMP data for 2000 show that the average price of retail heroin per milligram pure in the United States was $0.77, and the average purity was 37.2 percent. Heroin prices have continued to drop since the early 1990s, while purity has increased. The price and purity in 2000 is in stark contrast to 1980, when heroin per milligram pure sold for $3.90 and the purity level was only 3.6 percent.

The DEA officials also noted that there is concern that Mexican traffickers may be attempting to produce white powder heroin.

Officials of DEA's Intelligence Division provided an overview of two programs designed primarily to detect trends in the supply of heroin in the United States--the Heroin Signature Program (HSP) and the Domestic Monitor Program (DMP). HSP provides data on heroin wholesale trafficking and distribution patterns, based on 600-900 samples annually. The samples are taken from port of entry seizures as well as randomly selected DEA seizures and purchases. DEA chemists associate the HSP samples with a heroin production process or "signature" that is indicative of a particular geographic area. The analyses provide insight into the routes and methods used to smuggle heroin into the United States.

DMP collects and analyzes data on the purity, price, and origin of retail-level heroin in 23 metropolitan areas. Undercover purchases of heroin are made quarterly (without arrests) at the retail level and are then analyzed to determine purity and the geographic source of the heroin. DMP data for 2000 show that the average price of retail heroin per milligram pure in the United States was $0.77, and the average purity was 37.2 percent. Heroin prices have continued to drop since the early 1990s, while purity has increased. The price and purity in 2000 is in stark contrast to 1980, when heroin per milligram pure sold for $3.90 and the purity level was only 3.6 percent.

The DEA officials also noted that there is concern that Mexican traffickers may be attempting to produce white powder heroin.