Contents

At this meeting, CEWG members, NIDA officials, and international representatives paid a special farewell tribute to Nicholas J. Kozel, NIDA, who founded the Community Epidemiology Work Group in 1976 and nurtured its development into a widely recognized and acclaimed drug abuse surveillance system. The CEWG model has been emulated in many countries and regions of the world, including Africa; Asia; Australia; North, Central, and South America; and Europe, all with the assistance and encouragement of Mr. Kozel.

This Advance Report is a synthesis of findings presented at the 53rd meeting of the Community Epidemiology Work Group (CEWG) held in Miami, Florida, on December 10-13, 2002. Sponsored by the National Institutes of Health, National Institute on Drug Abuse (NIDA), the CEWG is a network of epidemiologists and researchers in the United States that meets semiannually 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 analyzed. Sources include public health agencies, medical and treatment facilities, medical examiners' and coroners' offices, criminal justice and correctional offices, State and local law enforcement agencies, poison control centers, telephone hotlines, 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 (TEDS) 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); and drug seizure data from the United States Customs Service. CEWG data are enhanced with qualitative information obtained from ethnographic research, focus groups, and other community-based sources.

The CEWG areas include the following:

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 December meeting, members were provided an update on the Drug Abuse Warning Network. In addition, special presentations were made on drug abuse problems and programs in South Florida. They included presentations by:

• A law enforcement official with the Strategic Investigations Division, Broward County Sheriff's Office, who described drug diversion and drug problems identified in the region.
• The Director of the Toxicology Office, Miami-Dade County, who reported on the types of drug problems identified in Dade County toxicology reports.
• A psychotherapist who works with groups involved in polydrug abuse and members of the gay community.
• A faculty member of the College of Pharmacy, Nova Southeastern University, who reported on the toxicology of substances abused alone and in combination, in South Florida.
• A Special Agent/Demand Reduction Coordinator with the Miami Field Division, DEA, who described the club drug scene in South Florida and the drug prevention and outreach efforts to high-risk populations.
• The President of Spectrum Programs, who described drug abuse treatment methods and approaches used in South Florida.

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

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

Cocaine/Crack continues to be the predominant illicit drug in most CEWG areas, despite declining indicators in recent years. There were reports in seven areas that powder cocaine was more available and cheaper in street markets than in past years (see pages 5-11).

Heroin abuse indicators increased among young White and suburban populations in several CEWG areas. Ongoing research is needed to determine the extent to which these users switch from inhalation to injection of this drug (see pages 11-19).

Other Opiate abuse indicators continue to trend upward, with increased use of controlled substances reported in almost all CEWG areas. Oxycodone, hydrocodone, and methadone abuse indicators increased in most CEWG areas. Research efforts are underway in some areas to assess the extent to which these drugs (used medically in the treatment of chronic pain) are diverted to illicit markets and are being abused (see pages 19-25).

Marijuana abuse indicators continued to increase in 10 CEWG areas. In 2001, high proportions of clients entering treatment programs in Minneapolis/St. Paul (49.2 percent), Colorado (40.6), New Orleans (37.5), Seattle (34.4), St. Louis (33.3), Hawaii (28.6), Texas (26.0), Illinois (25.9), San Diego (25.9), and New York (25.2) were primary marijuana abusers (see pages 26-32).

Methamphetamine abuse indicators remained high in Hawaii, all west coast CEWG areas, and Phoenix. Abuse of the drug has continued to spread to Denver, Detroit, and Minneapolis/St. Paul and there is increased evidence that it is spreading to populations in east coast areas (e.g., Atlanta, Miami, New York City, and Washington DC). (see pages 32-38).

MDMA (methylenedioxymethamphetamine or "ecstasy") indicators have increased as the abuse of this drug became more widespread in most CEWG areas (see pages 38-46).

Cocaine/Crack

Across CEWG areas, cocaine/crack indicators continued a pattern of stabilization or decline, with indicators remaining mixed in 10 areas. The only area reporting increases was San Francisco, where cocaine/crack indicators were relatively low compared with other CEWG areas. The two areas reporting decreases were New Orleans and Newark. Indicators were stable in the other eight CEWG areas. Cocaine/crack continues to be the predominant illicit drug in most CEWG areas, despite declining indicators in recent years. In Philadelphia, for instance, the CEWG member reported that "cocaine/crack remains the major drug of abuse," even though indicators have stabilized.

Some examples of the mixed pattern of cocaine/crack indicators are cited below.

Chicago Indicators of cocaine use have leveled off from previous increases, but some began to show slight increases in 2000. Many cocaine indicators remain the highest for all substances except alcohol.

Honolulu In the first 6 months of 2002, there was a slight increase in primary cocaine/crack treatment admissions but a decrease in deaths involving cocaine. Prices of the drug have remained stable, despite increased cases reported by police departments in recent years.

San Diego From 2000 to 2001, three cocaine indicators decreased, while cocaine (primary drug of abuse) treatment admissions increased.

Seattle Cocaine indicators pointed to a return to high levels of mortality at the same time treatment admissions and ED mentions declined.

Texas Cocaine indicators are mixed, with cocaine-related deaths increasing, treatment admissions stable, and the rate of cocaine/crack ED mentions in Dallas down significantly from 2000 to 2001. Cocaine is a significant problem on the border.

Washington D.C. While most cocaine indicators are down, cocaine remains the most widely abused illicit drug in the District. Deaths associated with cocaine remained relatively stable from 1996 to 2000 (57 and 54, respectively). ED mentions in 2001 were at a 5-year low.

In 2001, the highest estimated rates of cocaine ED mentions in DAWN were in the eastern half of the Nation, some areas in the Midwest, and on the west coast. The rates of cocaine ED mentions exceeded 200 per 100,000 population in 5 CEWG areas: Chicago (277), Philadelphia (252), Atlanta (244), Miami (225), and Baltimore (214). Rates exceeded 100 per 100,000 population in Boston, Detroit, Los Angeles, New Orleans, Newark, New York, St. Louis, San Francisco, and Seattle (exhibit 1).

Exhibit 1. Rates of Cocaine ED Mentions Per 100,000 Population by CEWG Area: 2001

SOURCE: Adapted from DAWN, Office of Applied Studies, SAMHSA

Trend data from 1999 to 2001 show that two of the CEWG areas with the highest rates of cocaine ED mentions per 100,000 population experienced significant increases: Chicago (between 1999 and 2001) and Atlanta (between 1999 and 2001, and between 2000 and 2001) (exhibit 2). Cocaine ED rates also increased significantly in both time periods in Boston, Minneapolis/St. Paul, and San Francisco, with Los Angeles and Seattle showing significant increases between 1999 and 2001. Significant decreases in one or both time periods occurred in Baltimore, Dallas, New Orleans, Newark, and San Diego.

Exhibit 2. Trends in Rates of Cocaine ED Mentions Per 100,000 Population in CEWG Areas by Year: 1999-2001

The increases in cocaine ED rates shown in exhibit 2 continued the trend reported for "percent change" between 1994 and 2001 in Atlanta and Minneapolis/St. Paul.

Excluding admissions for alcohol-only and alcohol-in-combination with other drugs, 2001 treatment data from 19 CEWG areas show that Atlanta had the highest proportion of persons admitted for primary abuse of cocaine/crack (approximately 68 percent), followed by St. Louis (44 percent), Washington, DC (41 percent), New Orleans and Philadelphia (each 40 percent), and Detroit and Texas (each 39 percent) (exhibit 3).

The proportions of primary cocaine/crack admissions in seven CEWG areas ranged between 21 percent (Colorado and San Francisco) and 32 percent (Illinois). Primary cocaine/crack admissions in Boston, Baltimore, San Diego, Hawaii, and Newark were considerably lower, ranging from 7 percent (Newark) to 16 percent (Boston).

Exhibit 3. Primary Cocaine/Crack Treatment Admissions (Excluding Alcohol) by CEWG Area and Percent: 2001

SOURCES: CEWG reports and, for San Francisco, the California Drug Data System

ADAM data show that the proportions of adult male arrestees testing cocaine-positive in 2001 were highest in New York (44.6 percent), Chicago (40.6 percent), New Orleans (37.3 percent), and Philadelphia (36.7 percent) (exhibit 4).

Exhibit 4. Percentages of Adult Male Arrestees Testing Cocaine-Positive by Site: 2001

SOURCE: ADAM, NIJ

A comparison of the weighted samples from 2000 and 2001 show that the percentages testing cocaine-positive increased in six CEWG areas, remained relatively stable in four sites, and decreased in another four. The increase was greatest in San Antonio (9.2 percentage points), while the decrease was greatest in Laredo (10.1 percentage points).

ADAM 2001 data on the (unweighted) adult female samples were reported from six CEWG areas. Among these small samples, cocaine-positive screens were highest in New York (56.9 percent), Denver (45.0 percent), and New Orleans (38.1 percent) (exhibit 5). Compared with 2000 test results, substantial decreases were reported for Honolulu and San Diego (each more than 9.5 percentage points). In several CEWG sites, no ADAM data were collected for females in 2001.

Exhibit 5. Percentages of Adult Female Arrestees Testing Cocaine-Positive by Site: 2001

SOURCE: ADAM, NIJ

In most CEWG areas, crack continues to be the preferred form of cocaine, as indicated in the following excerpts from CEWG reports.

Atlanta Smoking remains the preferred route of administration among cocaine admissions, at 62 percent or more.

St. Louis Most cocaine users smoke crack cocaine. Younger users smoke cocaine exclusively. The continued use of cocaine, particularly crack by urban women, has potentially severe long-term consequences by contributing to the spread of sexually transmitted diseases (STDs) through multiple partners. Numerous small behavioral studies of crack-abusing women have found that crack use is predictive of multiple partners and HIV risk exposure. The STD rate in St. Louis has decreased for men, but remains high for women.

San Diego Within the primary cocaine abuser treatment population in 2001, 85 percent reported smoking as the preferred mode of cocaine use.

Washington, DC The number of persons entering treatment for crack abuse accounted for 78 percent of all cocaine admissions in 2001.

Crack is reportedly widely available in CEWG areas, typically selling for $10 per "rock," and is trafficked in various ways.

Boston According to DEA, crack is 'more available in the inner cities' of New England.

Denver The DEA indicates that, despite declining use, crack cocaine availability remains stable in Colorado, with supplies continuing to come from street gangs in Los Angeles and Chicago. The crack is transported in passenger vehicles, commercial buses, or airlines from the aforementioned cities. Upper-level crack organizations are primarily Mexican, with gang affiliations, and are intertwined with African-Americans, who control street-level distribution.

Minneapolis/St. Paul Seizures and law enforcement cases involving cocaine increased in 2002. Gangs continued to play a significant role in the street-level, retail distribution of cocaine (especially crack).

New York Of the 21,276 cocaine-related arrests in New York City from January to October 2001, 83 percent involved crack.

Texas In Austin, according to street outreach workers, crack cocaine is plentiful but quality is poor. Crack users who want to inject are now using citric acid rather than lemon juice, since it is less harmful to the veins. In El Paso, the number of crack users is reportedly increasing, particularly among young adult populations on the West Side.

Washington DC Individuals age 60 and older are reportedly being recruited as cocaine couriers, and a minority began selling crack cocaine from their residences in public housing projects.

Like other illicit drugs, crack is often used in combination with other drugs, and by an aging population, as exemplified in the Philadelphia report:

Crack users continue to report frequent use in combination with 40- ounce bottles of malt liquor, beer, or other drugs, including alprazolam (Xanax), diazepam (Valium), marijuana, or cigarettes. Powder cocaine, oxycodone (Percocet or OxyContin), and methadone were less frequently mentioned as drugs used with crack. The autumn 2002 focus groups continued to report an aging crack-using population, mostly in their late twenties through thirties, and estimated the crack-using population was 54 percent African-American, 24 percent White, 20 percent Hispanic, and 2 percent Asian.

Increases in powder cocaine abuse were reported in two CEWG areas.

Atlanta Information gathered ethnographically suggests that Atlanta may be seeing a return to more recreational cocaine use, with more powder available and a number of younger users reporting occasional snorting. Also, many younger users who are regular marijuana smokers are talking of mixing in small amounts of cocaine known as 'boonts,' 'fruities,' or 'geek joints,' particularly when using blunts. Some specifically mention powder cocaine and some crack cocaine, though the preference may have much to do with availability.

San Francisco Cocaine use prevalence appears to be rising again, after a significant decline in the 1990s. The shift away from smoking crack toward snorting powder persists. The former predominance of Blacks among users continues to ebb.

Powder cocaine remained widely available in CEWG areas.

Denver The DEA reports the substantial availability of cocaine powder across the State in ounce, pound, and kilogram quantities. Mexican polydrug trafficking groups control the majority of cocaine distribution in the Denver metropolitan area through Hispanic, White, and African-American distributors. Most cocaine is brought into Colorado in vehicles from the southwest border and southern California on interstate and local highway systems. Kilograms of cocaine are often sold in bricks covered in industrial tape. Smaller amounts of cocaine are usually packaged in zip-lock plastic bags with no special markings.

Detroit Numerous organizations distribute cocaine in the metropolitan area and statewide. Gangs control a number of distribution points and are major suppliers to many markets. Some dealers have switched to selling marijuana because of the more severe consequences for selling cocaine. The Detroit metropolitan area remains a source hub for other areas of Michigan and the larger Midwest region.

Phoenix While indicators for cocaine/crack remained unchanged or decreased slightly, cocaine hydrochloride is consistently available throughout the Phoenix, Tucson, and Nogales areas of Arizona, according to the DEA. Wholesale cocaine is primarily sold in powder form in kilogram and half-kilogram pressed bricks wrapped in cellophane and packaging tape. Recently, wrappings have included Mylar material and black carbon paper.

St. Louis Cocaine retains a strong presence in all urban indicators, but indicators are typically stable. Local law enforcement sources, the DEA, and street informants continued to report high quality, wide availability, and low prices for cocaine.

Texas The DEA reported in the first half of 2002 that powder cocaine was abundant. Use among youth on the border is higher than in nonborder areas, according to the Texas Secondary School Survey: 13 percent of students on the Texas border had used powder cocaine lifetime, compared with 7.2 percent of nonborder students.

Heroin

Heroin indicators increased in four CEWG areas, decreased in one, were stable in seven, and were mixed in nine.

Despite mixed patterns, heroin abuse indicators remain high in many CEWG areas. Primary heroin treatment admissions increased in such areas as Chicago and San Diego, as well as in Boston and Newark, where all heroin indicators increased. Despite declines in heroin treatment admissions in other areas, heroin continues to account for large proportions of admissions in several CEWG areas, including Baltimore, Chicago, Los Angeles, and New York. Denver reported a 73-percent increase in opiate occurrences in hospital discharges from 1995 to 2001 (from 29.4 to 50.8 per 100,000 population). The Denver representative also reported increases in heroinrelated calls to the poison control center (from 12 in 2000 to 36 in 2001), and the Texas representative documented increases in confirmed exposure to heroin in the Texas Poison Control Centers (from 168 in 1998, to 231 in 1999, to 265 in 2000, and to 184 in the first three quarters of 2002). Increases in heroin-involved deaths were reported in Detroit, Honolulu, Newark, Minneapolis/St. Paul, San Diego, and Seattle. The Washington, DC, representative reported that "heroin has surpassed crack as the drug associated with the most serious consequences: medically, legally, and in overall effects to society." The Minneapolis/St. Paul representative reported a similar finding: "The heightened level of heroin-related indicators continued in 2002. Opiate-related deaths, most from accidental heroin overdose, again surpassed those from cocaine in both cities, fueled by high-purity heroin at low prices and in steady supply."

The areas where heroin indicators increased were Atlanta, Boston, Detroit, and Washington, DC. In Atlanta, where heroin indicators are low, a new pattern of heroin use is emerging:

As heroin use increases in Atlanta, the characteristics of its users may be shifting. In particular, many young adults who are regular MDMA users admit to including heroin in their drug use or simply moving to heroin as their primary drug of choice.

Other CEWG areas are experiencing increases in young heroin abusers, some of whom prefer inhalation and some injection of the drug:

Baltimore Heroin was the primary drug responsible for one-half of drug-related treatment admissions in 2000. Inhalation of the drug was more prevalent than injection. Among injectors, there were two populations. One was Black, age 35-45. The other was White and younger, with the peak age at admission being 27. Women outnumbered men among heroin treatment admissions younger than 30. While rates per 100,000 population (age 12 and older) declined in the city in 2001, rates increased in the suburbs.

Newark Heroin injection among 18-25-year-old treatment clients in Newark continued to rise, reaching a high of 36.5 percent in 2001; the pattern of injection among the age 18-25 client group was also evident statewide.

Philadelphia According to focus groups, comprised of drug users in treatment in autumn 2002, new heroin users in the city begin using the drug in their late teens. The average user injects heroin five times a day; 33 percent of heroin users use heroin only, with 59 percent also using crack and 8 percent using heroin and powder cocaine in speedball injections.

San Francisco While the average age of heroin users continues to increase, ethnographic observers report an increase among younger Whites, most of whom do not inject. Older users still prefer the injection route.

Exhibit 6. Rates of Heroin ED Mentions Per 100,000 Population by CEWG Area: 2001

SOURCE: Adapted from DAWN, Office of Applied Studies, SAMHSA

In 2001, the rates of heroin ED mentions exceeded 200 per 100,000 population in Newark (215) and Chicago (203). In Baltimore, Boston, New York, Philadelphia, and San Francisco, heroin ED rates exceeded 100 per 100,000 population (exhibit 6).

Trend data presented in exhibit 7 show significant increases in heroin ED rates between 1999 and 2001 and 2000 and 2001 in Atlanta, Boston, Detroit, Miami, and Minneapolis/St. Paul, but significant decreases in Baltimore, New Orleans, Newark, San Diego, and Seattle. Between 2000 and 2001, rates of heroin ED mentions also decreased in Denver and Los Angeles.

Exhibit 7. Trends in Rates of Heroin ED Mentions Per 100,000 Population in CEWG Areas by Year: 1999-2001

¹ These columns denote statistically significant (p<0.05) increases and decreases between estimates for the time periods noted.
SOURCE: Adapted from DAWN, Office of Applied Studies, SAMHSA

The increases shown in exhibit 7 for Atlanta, Boston, Chicago, Detroit, Miami, and Minneapolis/St. Paul continued the trend of significant increases in heroin ED rates in these areas between 1994 and 2001.

Excluding alcohol, treatment data for 2001 in 19 CEWG areas show that the proportions of persons admitted for primary heroin abuse were greatest in Newark (approximately 86 percent), Boston (74 percent), San Francisco (63 percent), and Baltimore (61 percent). In Detroit, Los Angeles, Washington, DC, and New York, between 43 and 47 percent of admissions were for primary heroin abuse, followed by Philadelphia (34 percent), Illinois (25 percent), and Seattle (24 percent). In the other eight reporting areas, primary heroin admissions accounted for between 5 percent (Hawaii) and 18 percent (New Orleans) of all illicit drug treatment admissions (exhibit 8).

Exhibit 8. Primary Heroin Treatment Admissions (Excluding Alcohol) by CEWG Area and Percent: 2001

SOURCES: CEWG reports and, for San Francisco, the California Drug Data System

ADAM data on adult male arrestees in 14 CEWG areas in 2001 show that the percentages testing opiate-positive ranged from 3.4 percent in Honolulu to 21.8 percent in Chicago (exhibit 9). Substantial proportions also tested opiate-positive in New York (18.7 percent), New Orleans (15.6 percent), and Philadelphia (13.2 percent).

Exhibit 9. Percentages of Adult Male Arrestees Testing Opiate-Positive by Site: 2001

SOURCE: ADAM, NIJ

Compared with 2000, the proportions of adult male arrestees testing opiate-positive in the 14 CEWG sites shown in exhibit 9 remained relatively stable in most sites, increasing only between 1.4 and 1.8 percentage points in Dallas, Denver, and Miami, and decreasing less than 2 percentage points in 9 areas. Honolulu and Chicago reported the largest decreases in opiate-positive screens among adult male arrestees (3.4 and 5.2 percentage points, respectively).

Among the smaller adult female samples in 2001, opiate-positive tests were highest in New York (13.9 percent) and Laredo (10.2 percent) (exhibit 10).

Exhibit 10. Percentages of Adult Female Arrestees Testing Opiate-Positive by Site: 2001

SOURCE: ADAM, NIJ

At the seven sites included in exhibit 10, only Laredo reported a notable increase from 2000 in opiate-positive screens among female arrestees--3.3 percentage points. The largest percentage point decreases occurred in New York (5.2 points), Honolulu (4.1), and Denver (3.4). As noted earlier, no ADAM data on females were collected in several CEWG sites in 2001.

Preliminary DMP data showed that the average purity of heroin in 2001 was approximately 34 percent across 22 cities in the United States and San Juan, Puerto Rico. In the 21 CEWG areas depicted in exhibit 11, 10 exceeded the overall average. The highest average heroin purity was found in Philadelphia (73), Newark (68), Boston (57), New York (56), and Atlanta and Detroit (49 each). CEWG areas in the western and southwestern cities near the U.S.-Mexico border also had relatively high average heroin purity levels, ranging from 41 in Phoenix to 45 in San Diego.

Data indicate that heroin is available in CEWG areas, primarily white heroin in areas east of the Mississippi River and Mexican black tar in areas west of the river. Trafficking patterns vary across areas.

Chicago The DEA estimated that in the first half of 2001, 50 percent of the heroin in Chicago was from South America.

Denver The Denver DEA reports that heroin is widely available in the large metropolitan areas. In the Denver metropolitan area, the majority of heroin sales take place in the lower downtown area. Marketing is controlled by Mexican nationals. They also control the street-level heroin market in the form of small, autonomous distribution cells. Street-level heroin is usually packaged in balloons, plastic sandwich bags, or tin foil for gram and ounce quantities. Larger seizures have encountered heroin wrapped in wax paper, further contained within foil paper and clear plastic wrap, and then flattened out to fit in hidden compartments. Street-level heroin is usually sold in grams.

Detroit Nearly all available heroin remains white in color. South America (Colombia) remains the dominant source, although in the past 3 years or so, heroin originating in both Southeast Asia and the Middle East has been identified. Heroin street prices have remained relatively stable and low in Detroit.

Honolulu Black tar heroin monopolizes the heroin market in Hawaii and is readily available in all areas of the State.

Minneapolis/St. Paul The heroin seized by law enforcement in Hennepin County was typically white, off-white, or tan powder. The most common in Ramsey County was dark-colored, Mexican black tar heroin.

Phoenix Heroin indicators remained unchanged or decreased slightly. Black tar heroin remains the most frequently encountered form of heroin used by the well-established 'traditional' community of heroin abusers in the Phoenix and Tucson metropolitan areas. Colombia and Mexico are the two major sources of heroin that enters Arizona. It has been reported that Mexican traffickers are increasing the purity in order to compete with Colombian heroin. Mexico suffered from a severe drought for an extended time, which significantly impacted heroin production. Rainfall has returned to normal, and opium poppy cultivation has also returned to normal.

St. Louis Heroin of reasonable purity has continued to be available but is also quite expensive in St. Louis compared to other cities. This midwestern city is a destination market. Most business is handled by cellular phone, which has decreased the seller's need to have a regular location, thus reducing the risk of being arrested. In St. Louis and other smaller urban areas, heroin is sold by small distribution networks, as well as by many small entrepreneurs. Wide sampling of the available drug quality can be difficult because identification is more difficult in this compact, free enterprise distribution system.

San Diego Heroin seizures at the combined San Diego and Imperial County border increased 243 percent from 2000 to 2001, when 207 kilograms were seized, accounting for 54.8 percent of all heroin seized at border points of entry. The 2001 seizures were the highest of any in the recent 5-year period.

Texas The DEA reports that, typically, heroin is more available, and heroin from Mexico is increasing in purity. Reports have been received of white heroin now being produced in Mexico. In Laredo, a free sample of white heroin 95 percent pure was obtained in summer 2002.

Washington, DC Of heroin samples seized in the District in 2001, 14 were South American, 13 were Southwest Asian, and 2 were of unknown origin.

Exhibit 11. Domestic Monitor Program - Average Heroin Purity in 21 CEWG Areas: 2001

SOURCE: DMP, DEA

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 narcotic analgesics and narcotic analgesic combinations, including hydrocodone and oxycodone. As researchers in Seattle point out, an issue that will continue to be explored is to what degree recent indicator data point to abuse of "other opiate" medications versus an increase in legitimate prescriptions by physicians. Physicians have been prescribing these medications to help patients manage pain, a condition that has historically been under-medicated.

DAWN ED estimates for the coterminous United States show that mentions of narcotic analgesics/combinations increased 21 percent between 2000 and 2001 and 123 percent from 1994 to 2001.

Across CEWG areas in 2001, rates of narcotic analgesics/combinations per 100,000 population were higher than rates of heroin ED mentions in seven CEWG areas: Atlanta, Dallas, Denver, Minneapolis/St. Paul, Phoenix, San Diego, and Seattle. The highest rates were in Seattle (120), Baltimore (114), and Boston (81) (exhibit 12). Thirteen CEWG areas experienced significant increases in rates from 2000 to 2001, with only one showing a significant, but modest, decrease.

Exhibit 12. Rates of Narcotic Analgesics/Combinations ED Mentions Per 100,000 Population by CEWG Area: 2001

SOURCE: Adapted from DAWN, Office of Applied Studies, SAMHSA

Rates of ED narcotic analgesics/combinations have been trending up for several years. Exhibit 13 shows trends for three time periods tested in DAWN. As shown, statistically significant increases occurred in all 20 CEWG areas included in DAWN in at least 1 time period, with decreases found in only 2 areas in 1 of the time periods.

Exhibit 13. Trends in Narcotic Analgesics/Combinations Mentions Per 100,000 Population in CEWG Areas by Year: 1994, 1999-2001

¹ These columns denote statistically significant (p<0.05) increases and decreases between estimates for the time periods noted.
SOURCE: Adapted from DAWN, Office of Applied Studies, SAMHSA

Exhibit 14 shows the number of ED mentions of narcotic analgesics/ combinations in 14 CEWG areas where significant increases were reported between 2000 and 2001. The percentage changes ranged from a low of 15 percent in Detroit to 63 percent in Washington, DC. Although there were no significant changes between 2000 and 2001, the numbers of narcotic analgesics/combinations were high in three other CEWG areas: Atlanta (1,108), Los Angeles (2,135), and Philadelphia (3,027).

The two most frequently mentioned narcotic analgesics/combinations in 2001 were hydrocodone or hydrocodone combinations and oxycodone/combinations.

Hydrocodone

In 2001, the highest ED rates of hydrocodone/combinations per 100,000 population were in New Orleans (18), Phoenix (13), and Dallas, Denver, San Diego, and San Francisco (each 12). From 2000 to 2001, the number of ED hydrocodone/combinations increased in nine CEWG areas. In four CEWG areas, mentions of hydrocodone/combinations increased between 53 and 58 percent: New York (from 62 to 98 mentions), Philadelphia (132 to 208), Minneapolis/St. Paul (122 to 188), and Phoenix (240 to 367). In another three CEWG areas, increases ranged between 24 and 30 percent: Detroit (371 to 483), Dallas (303 to 375), and San Diego (238 to 294). In the remaining two areas, mentions increased 11-12 percent: Baltimore (41 to 46) and San Francisco (169 to 188).

The following quotes from CEWG reports exemplify the increasing abuse of hydrocodone and related problems.

Detroit There were further increases in hydrocodone indicators (typically Vicodin, Lortab, or Lorcet). There was a 443-percent increase in hydrocodone ED mentions between 1994 and 2001. The drug was identified by the Wayne County ME lab in 60 decedents in 2000, 80 in 2001, and 66 from April through September 2002. The Children's Hospital of Michigan Poison Control Center in 2001 showed 40 intentional hydrocodone abuse cases; 39 were identified in the first 9 months of 2002.

Miami Hydrocodone is appearing increasingly in crime lab tests. ED mentions of hydrocodone have increased. A total of 248 hydrocodonerelated deaths were reported in Florida during the first half of 2002, with 9 being in the Miami-Dade County area.

Minneapolis/St. Paul Hospital ED mentions involving hydrocodone/hydrocodone combinations more than doubled from 1994 to 2001. The 188 mentions of hydrocodone/hydrocodone combinations in 2001 represented 19.7 percent of the total narcotic analgesics/combinations mentions; 177 (out of 188) were hydrocodone with acetaminophen (Vicodin). Hydrocodone-related calls to the Hennepin Regional Poison Center grew from 5 in 2000 to 16 in 2001 (through September).

Philadelphia Hydrocodone mentions in mortality cases have increased.

Phoenix The Phoenix DEA Diversion Group reports that Vicodin, Lortab, and other hydrocodone products were among the commonly abused pharmaceutical controlled substances in the area.

Seattle ED mentions of hydrocodone and its combinations (e.g., Vicodin and Percocet) increased significantly between 1999 and 2000, with similar levels in 2001. According to the local DEA, hydrocodone is the most common diverted narcotic. This is due in large part to its status as a Schedule III drug under the Controlled Substances Act.

Texas Hydrocodone is a larger problem in Texas than oxycodone. The number of ED hydrocodone/combinations in Dallas increased significantly between 1994 (n=214) and 2001 (375). Deaths involving hydrocodone mentions in Texas rose from 25 in 1999 to 107 in 2001.

Exhibit 14. Number of Narcotic Analgesics/Combinations ED Mentions in 14 CEWG Areas: 2001

SOURCE: Adapted from DAWN, Office of Applied Studies, SAMHSA

Oxycodone

ED rates of oxycodone/combinations per 100,000 population in 2001 were highest in Boston (27), Philadelphia (24), Seattle (12), and New Orleans and Phoenix (each 11). The number of oxycodone/ combinations mentions increased significantly in 16 CEWG areas. The highest number of mentions in 2001 was found in Philadelphia (1,062) while the greatest percentage change was in Washington, DC (157 percent). The areas are listed in each rank order of "percent change" in exhibit 15.

Exhibit 15. CEWG Areas Where Mentions of ED Oxycodone/Combinations Increased Significantly from 2000 to 2001

¹ This column represents statistically significant (p <0.05) increases between estimates for the time period noted.
SOURCE: Adapted from DAWN, Office of Applied Studies, SAMHSA

In the January 2001 Information Bulletin, the National Drug Intelligence Center (NDIC) addresses the diversion and abuse of the prescription pain reliever OxyContin, noting that abuse of this drug is a major problem, particularly in the eastern part of the United States. This oral, controlled-release form of oxycodone acts for 12 hours, making it the longest-acting oxycodone on the market. While this Schedule II drug is designed to be swallowed whole, abusers ingest the drug in various ways, including chewing the tablet or crushing it and snorting the powder. Crushed tablets are also dissolved in water and then injected. Both snorting and injecting the drug lead to the rapid release and absorption of oxycodone.

Often referred to as "poor man's heroin," OxyContin nevertheless commands a high price on the street. A 40-milligram tablet selling for approximately $4 through prescription may sell for 50 cents to $1 per milligram on the street, depending on the geographic locality. The same 100-tablet bottle purchased for $400 at a pharmacy sells illegally for $2,000-$4,000.

OxyContin is diverted in various ways--by pharmacy diversion, "doctor shopping," and improper physician prescribing practices. Doctor shopping is the most widely used diversion practice, with individuals visiting numerous doctors (sometimes in several States) to acquire a large amount of the drug, which they abuse themselves or sell to others.

Sentencing guidelines for diverted Schedule II pharmaceuticals are determined by a tablet's total weight, not its strength. Thus, drugs of lower strength (e.g., Percocet and Tylox with 5 milligrams of oxycodone) may weigh more than OxyContin so that distribution of the same quantities of lower strength tablets may result in stiffer penalties than distribution of OxyContin.

Quotes from the CEWG areas below typify the increasing concern about the abuse of oxycodone products.

Atlanta Ethnographic data support the idea that use of other opiates is common, especially in nonmetropolitan counties. Specific drugs like OxyContin, Vicodin, and Dilaudid were mentioned by a number of clients in various methadone clinics as either their primary drug of choice upon entering treatment or as what they started with before moving on to heroin and subsequently into treatment. While the DEA sees OxyContin use as less of an issue in Georgia than in some surrounding States (e.g., South Carolina), Georgia did rank fifth in the Nation between 2000 and 2001 in the rate of pharmacy thefts for OxyContin.

Boston In 2001, Boston had the highest ED rate of oxycodone/combinations per 100,000 population (27) of all DAWN sites, increasing significantly from 2000. Six-month drug lab submissions showed a 57- percent increase in the number of oxycodone samples from 2000 to 2001 (233 vs. 365, respectively). A new pharmacy regulation, effective July 1, 2002, permits pharmacies to not stock OxyContin. Some pharmacies have displayed signs stating limited quantities of OxyContin in an effort to ward off thefts.

Detroit Since about 2000, oxycodone (OxyContin) has been increasingly reported by law enforcement agencies in arrests. OxyContin pills sell for $0.50-$1.50 per milligram. Some oxycodone is reportedly being smuggled from Canada.

Miami Oxycodone indicators were high but stable. The drug has received considerable 'negative press.'

Minneapolis/St. Paul The nonmedical use of prescription narcotic analgesics, particularly oxycodone, was identified as an emerging problem of expanding magnitude, as illustrated by hospital emergency department episodes, accidental deaths, and law enforcement activity.

Newark Oxycodone indicators increased. In the most recent statewide data available (2000), there were 4 deaths from oxycodone overdose and 57 oxycodone mentions in the ME cases.

Philadelphia The nonmedical use of oxycodone products continued to be reported by individuals in treatment, and focus groups reported the spread of oxycodone to all racial/ethnic groups.

Phoenix The Phoenix DEA Diversion Group reported that among the most commonly abused pharmaceutical controlled substances were Percocet, OxyContin, and other oxycodone products.

St. Louis OxyContin abuse remains a concern for treatment and for law enforcement. While prescription practices are closely monitored for abuse and isolated deaths have been reported, no consistent reports are available on the magnitude of this potential problem. It is the most frequently stolen drug in pharmacy robberies and costs $40 for an 80-milligram tablet on the street. Abuse of oxycodone (Percocet and Percodan) by prescription is growing in popularity.

San Francisco Ethnographic observers noted a strong increase in the presence of oxycodone in the street-scene. This is confirmed by DAWN ED data.

Seattle Oxycodone/combinations ED mentions increased significantly in recent years, doubling from 1999 to 2000 and increasing another 52 percent from 2000 to 2001. In the first half of 2002, oxycodone was identified in 13 deaths in the Seattle area.

Texas The number of ED mentions of oxycodone in Dallas DAWN increased significantly from 1994 (n=8) to 2001 (42), and the number of deaths with a mention of oxycodone increased from 8 in 1999 to 40 in 2001. In Tyler, OxyContin was reported to be more popular than hydrocodone as the drug of choice among heroin addicts.

Washington, DC The illegal use of OxyContin, the time-release version of oxycodone, has emerged as a substantial threat to the residents of DC. Users were reported to be as young as 15. Opiates such as oxycodone (Percocet, Percodan), Tylenol with codeine, and occasionally Dilaudid can be purchased near methadone clinics throughout the city.

Methadone

Reports from several CEWG areas point to increasing diversion of methadone, not only from methadone maintenance treatment programs but also from private physicians who prescribe this medication as a painkiller. In the first half of 2001, there were 254 deaths involving methadone in Florida. In DAWN, ED mentions of methadone increased significantly in 12 CEWG areas between 1994 and 2001 (exhibit 16).

Exhibit 16. Number of Methadone ED Mentions and Percent Change: 1994-2001

¹ This column represents statistically significant (p<0.05) increases between estimates for 1994 and 2001.
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

Marijuana

Marijuana indicators increased in 7 CEWG areas, were stable in 3, and were mixed in 11. Excerpts from the reports from CEWG areas where marijuana indicators increased are presented below. Some highlight the use of multiple drugs in this population and/or the use of marijuana among other drug-abusing populations.

Atlanta Ethnographic data confirmed that marijuana use is pervasive in metropolitan Atlanta. Individuals of all racial, ethnic, and socioeconomic spheres reported everything from occasional use to multiple daily use. It seems that, aside from nominal concern of encounters with law enforcement, marijuana is grouped more closely with alcohol and tobacco than with other illicit drugs. While not all marijuana users consumed other substances, most users of other drugs reported at least some marijuana use.

Baltimore Marijuana ED and treatment rates per 100,000 population increased slightly.

Chicago Marijuana use, alone and in combination with other drugs, appeared to be increasing, especially among youth in the Chicago metropolitan area. Data from the Chicago Youth Behavior Risk Survey showed that the proportions of high school students who reported ever using marijuana, and who were currently using marijuana, steadily increased from 1993. In 2001, nearly 50 percent of 9th-12th graders reported using marijuana at least once in their lifetime, and 29 percent reported current use. In general, currently available marijuana was of high quality. On the street, marijuana is most often sold in bags for $5-$20 or as blunts.

Miami Marijuana indicators were up. At Broward General Medical Center in the first half of 2002, marijuana accounted for 37 percent of the 1,249 illicit drug use cases and for 59 percent of the 268 cases among those age 12-25. Twenty-six percent of the cases visited the ED because of depression or suicidal tendencies. Twenty-one percent of Florida middle/high school students said using marijuana is not wrong; this group of students reported high levels of marijuana use.

Minneapolis/St. Paul Marijuana indicators increased. Marijuana cigarettes, 'joints,' are sometimes dipped in other psychoactive substances, such as phencyclidine (PCP) and formaldehyde, to achieve additional, more pronounced effects or to enhance the effects of marijuana alone.

St. Louis Marijuana indicators have been trending up in St. Louis for some time. As a potential gateway drug to more serious drug abuse, marijuana is being seriously targeted in local prevention efforts and in the educational system.

San Francisco Ethnographic observers noted an increase in marijuana use among young people. The proportion of females in ED marijuana mentions increased significantly between 2000 and 2001, although males accounted for more than two-thirds of the marijuana mentions.

Seattle Of marijuana ED mentions, 71 percent were also using other drugs at the time of the ED visit. The surge in the rate of marijuana mentions since the first half of 2000 has been maintained through 2001.

In Washington, DC, where marijuana indicators are mixed, there is "a growing concern about the increasing number of Hispanic residents who cite marijuana as their drug of choice." In San Diego, all marijuana indicators, except the percentage of marijuana-positive screens among adult male arrestees, are on the increase. In Detroit, marijuana continues to be the "top illicit drug," with indicators either stable or increasing. In Denver, marijuana hospital discharge occurrences per 100,000 population rose dramatically, from 45.6 in 1995 to 62.5 in 2001, and marijuana-related calls to the Rocky Mountain Poison and Drug Center rose from 1 to 2 per year between 1994 and 1998, to 47, 58, and 97 calls in 1999, 2000, and 2001, respectively. Among Texas secondary school students in 2002, 32 percent reported ever trying marijuana, and 14 percent had used it in the past month. In New York City, primary marijuana treatment admissions increased, with the average age being 24.9, and cannabis-related arrests increased, accounting for 46 percent of drug arrests between January and October 2001. In Los Angeles County, where marijuana is the most widely used drug, marijuana was the primary drug for which 65 percent of youth (under age 18) entered treatment between January and June 2002.

The phenomenon of polydrug use among marijuana users, noted earlier in Atlanta, Chicago, and Minneapolis/St. Paul, was also reported in two other CEWG areas:

Philadelphia Focus groups reported the increased availability and use of commercial blunt wrappers made of cigar tobacco leaves as an alternative to buying cigars for wrapping marijuana and other additives. Focus groups in autumn 2002 estimated that 37 percent of blunts were laced with PCP and 15 percent with crack. Blunt users commonly ingested beer, wine coolers, whiskey, alprazolam, or diazepam along with blunts and, less commonly, powder cocaine, vodka, barbiturates, clonazepam, oxycodone, and/or cough syrup.

Texas Use of marijuana joints dipped in embalming fluid that can contain PCP ('fry') continued, with cases seen in the poison control centers, emergency rooms, and treatment.

In 2001, the rates of marijuana ED mentions exceeded 100 per 100,000 population in Philadelphia (122 mentions), Detroit (121), and St. Louis (101), with rates ranging between 94 and 96 per 100,000 population in Atlanta, Boston, and Miami (exhibit 17). The lowest rates were in Dallas (34) and Newark (37).

Exhibit 17. Rates of Marijuana ED Mentions Per 100,000 Population by CEWG Area: 2001

SOURCE: Adapted from DAWN, Office of Applied Studies, SAMHSA

Between the two test periods shown in exhibit 18, the rate of marijuana ED mentions increased significantly in four CEWG areas: Minneapolis/St. Paul, San Diego, San Francisco, and Seattle. From 2000 to 2001, a significant increase was also found for Baltimore. Significant decreases in the rate of marijuana ED mentions were reported in only two sites--Phoenix (1999, 2001) and New Orleans (2000, 2001).

Exhibit 18. Trends in Rates of Marijuana ED Mentions Per 100,000 Population in CEWG Areas by Year: 1999-2001

¹ These columns denote statistically significant (p<0.05) increases and decreases between estimates for the time periods noted.
SOURCE: Adapted from DAWN, Office of Applied Studies, SAMHSA

There are indications that marijuana ED rates are stabilizing in most CEWG areas. First, the increases were significant from 2000 to 2001 in only five areas, with a decrease in another area. This contrasts with the differences between 1994 and 2001, when marijuana ED rates increased in 15 CEWG areas.

Excluding alcohol, treatment data from 19 CEWG areas for 2001 show that the proportions of primary marijuana mentions were highest in Minneapolis/St. Paul (approximately 49 percent), followed by Colorado (41 percent), New Orleans (37 percent), and St. Louis and Seattle (each 34 percent) (exhibit 19). In eight CEWG areas, primary marijuana admissions ranged from 19 percent of those admitted for treatment of an illicit drug (Baltimore) to 29 percent (Hawaii). Primary marijuana admissions ranged between 10 and 11 percent in Detroit and Los Angeles, and between 6 and 8 percent in Boston, Newark, San Francisco, and Washington, DC.

Exhibit 19. Primary Marijuana Treatment Admissions (Excluding Alcohol) by CEWG Area and Percent: 2001

SOURCE: CEWG reports and, for San Francisco, the California Drug Data System

Across ADAM/CEWG sites in 2001, more than one-half of adult male arrestees tested marijuana-positive in Chicago and Minneapolis (exhibit 20). In six sites, the percentage of marijuana-positive screens ranged from 40.0 to 47.8 percent. The one site with a percentage lower than 30 percent was Laredo.

Exhibit 20. Percentages of Adult Male Arrestees Testing Marijuana-Positive by Site: 2001

SOURCE: ADAM, NIJ

The percentages of adult male arrestees testing marijuana-positive in 2001 did not change substantially from the percentages testing positive in 2000 in five sites: Denver, Honolulu, Minneapolis, New York, and San Antonio. Increases were reported for Chicago and Phoenix (5.2 and 6.0 percentage points, respectively). The largest decrease was in Philadelphia (6.7 percentage points); percentagepoint decreases in other sites ranged between 1.7 (New Orleans) and 2.9 (Dallas).

In seven CEWG areas where ADAM data are reported on adult females in 2001, the percentages testing marijuana-positive were highest in Denver (33.0 percent) and New York (32.1 percent) (exhibit 21).

Exhibit 21. Percentages of Adult Female Arrestees Testing Marijuana-Positive by Site: 2001

SOURCE: ADAM, NIJ

Compared with 2000, the percentages of females testing marijuana positive remained stable in Denver and San Diego, while they decreased in other sites. Percentage-point decreases occurred in Honolulu (5.5), New York (3.9), Phoenix (3.2), and Laredo and New Orleans (each 2.9 percentage points).

The types and sources of marijuana vary within and across CEWG areas and seizures are not uncommon.

Atlanta The DEA asserts that marijuana continued to be the most widely used drug in the State. Much of the marijuana found in Georgia was brought in along the same route as other imported drugs--from the U.S. southwest border and often by Mexican nationals. In 2001, more than 5,200 kilograms of marijuana were seized throughout the State. Also, there was a significant amount of local marijuana growth.

Denver According to the Denver DEA, the most abundant supply of marijuana is Mexican grown and is trafficked from the border areas of Texas, New Mexico, and Arizona by Mexican polydrug trafficking organizations. Vehicles with hidden compartments are used to transport shipments ranging from pound to multipound quantities.

Detroit The majority of marijuana seizures in Michigan originated in Mexico, with some of it passing through the United States into Canada, where it was repackaged into smaller amounts and brought back to the United States. U.S. Customs officials reported sharp increases in seizures of hydroponically grown marijuana from Canada, being smuggled by Asian organized crime operations.

Phoenix The Yuma DEA reported encountering a form of marijuana known as 'chronic' or 'purple kush.' The leaves and stalk of the plant have a purple-tinge color. It is reported to sell for $20 per gram and $125 per one-quarter ounce, compared with the usual price of $20-$25 for one-quarter ounce. It is believed that chronic or purple kush may be a type of marijuana grown hydroponically in the San Francisco Bay area, where cooler weather might be a factor. The smoke is reported to be thick, musky, and spicy, and the high is immediate, almost opiate-like.

St. Louis Marijuana was available from Mexico or domestic indoor growing operations. Indoor production makes it possible to produce marijuana throughout the year. Therefore, law enforcement officials have been focusing more attention on indoor growing operations. In addition to the Highway Patrol Pipeline program, which monitors the transportation of all types of drugs on interstate highways, Operations Green Merchant and Cash Crop identify and eradicate crops. Much of the marijuana grown in Missouri is shipped out of the State.

San Diego In 2001, 209,675 kilograms of marijuana were seized at the San Diego/Imperial County border, a 65-percent increase from 1997 but a slight decrease (4 percent) from 2000.

Methamphetamines and Amphetamines

Methamphetamine indicators continue to be highest in Hawaii, west coast areas, and in parts of the Southwest. Amphetamine indicators tend to follow the same pattern. However, abuse of methamphetamine continues to spread in areas such as Atlanta, Chicago, Detroit, St. Louis, and Texas. Although indicators of methamphetamine abuse remained relatively low in east coast and mid-Atlantic CEWG areas, there is increasing evidence from community sources that this drug is increasingly being abused in some populations. For example, in New York City, methamphetamine abuse appears to be "especially on the rise among males in gay communities." Methamphetamine is available in New York City in powder, pill, and liquid form, with pills being the most popular.

The high rates of methamphetamine/amphetamine abuse in areas west of Denver will be apparent in the later presentation of DAWN, treatment, and ADAM data. What follows below are excerpts from reports in other areas where these indicators are increasing.

Atlanta As use of methamphetamine grows in the metropolitan Atlanta area, more users of other drugs are moving on from their drug of choice to methamphetamine for a variety of reasons. This was especially apparent among users of MDMA, who tended to begin by reporting occasional use of methamphetamine, as well as knowing that tablets sold as ecstasy often contain or are wholly 'speed.' Since many individuals developed some sort of tolerance for MDMA, they found it important to move on to a stronger, long-lasting high and if they enjoyed more speedy ecstasy, the move was often to methamphetamine, which could also be found at many of the parties and clubs that MDMA users might frequent. As was anticipated, the use of 'ice' and 'shards' was becoming more common. The manufacture of methamphetamine in Georgia was also becoming more common, though the labs cannot match the quantity that comes from outside the State. Many labs were very small, with authorities finding them in motel rooms and outbuildings, as well as set up in the backs of cars and trucks. They were also primarily found outside of Atlanta in more rural settings.

Chicago Methamphetamine ('speed') use in Chicago remained low, but it was more prevalent in many downstate counties. In October 2002, more methamphetamine was seized than cocaine or heroin in nearly 50 percent of Illinois counties. Within Chicago, a low but stable prevalence of methamphetamine use has been reported in some areas of the city in the past 2 years, especially on the north side, where young gay men, homeless youth, and 'ravers' congregate. Stimulants accounted for nearly 4 percent of all State treatment admissions (excluding-alcohol only) in FY 2001 and 2002, up 2 percent from FY 2000.

Denver Most indicators have increased over the past few years. Amphetamine-related hospital discharges increased from 19.4 to 26.3 per 100,000 population from 1995 to 2001. Amphetaminerelated calls (street drug category) to the Rocky Mountain Poison and Drug Center increased sharply in recent years from 291 in 1999 to 581 in 2001. Primary methamphetamine treatment admissions have doubled since 1996, representing 17.9 percent of all admissions in the first half of 2002. The DEA described widespread methamphetamine availability, with a majority of the drug originating from Mexico or from large-scale laboratories in California. However, the DEA made extensive lab seizures in the Rocky Mountain West (147 in April through June 2002). These laboratories, generally capable of manufacturing an ounce or less per 'cook,' varied from being primitive to quite sophisticated. The ephedrine reduction method remained the primary means of manufacturing methamphetamine in the area.

Detroit Indicator data showed increasing levels of methamphetamine abuse in the State, mostly in the southwestern corner of lower Michigan. Multimillion tablet seizures are now common. At least three methamphetamine labs have been found in the Upper Peninsula. Through October 2002, Michigan State Police had seized 172 labs; at this rate, the year-end total will easily double that of 2001.

Minneapolis/St. Paul Most indicators rose again in 2002. Methamphetamine-related calls to the Hennepin Regional Poison Center rose sharply from 7 in 2000 to 56 in 2001 (through September). Methamphetamine seizures increased. The State crime lab handled 883 cases in 2001 and 1,975 through September 2002. The St. Paul crime lab handled 365 cases in 2002 (through September), compared with 295 during the same time period last year. The growth of makeshift, do-it-yourself methamphetamine labs continued. In 2002 (through November 8) there were 230 clandestine methamphetamine labs shut down in Minnesota by the DEA, compared with 236 in 2001, and 138 in 2000.

St. Louis Methamphetamine, along with alcohol, remained primary drugs of abuse in both the outlying rural areas and statewide (because most of Missouri, outside of St. Louis and Kansas City, is rural). The Drug and Alcohol Services Information System report on admissions showed a statewide rate change from 7 per 100,000 in 1993 to 69 per 100,000 in 1999, an 873-percent increase in admissions statewide. Use of methamphetamine and its derivatives has also become more widespread among high school and college students, who do not consider these drugs as dangerous as others. Lab seizures have increased. In 2001, there were a reported 2,137 seizures of methamphetamine labs, dumpsites, and locations of inactive labs in Missouri. Locally produced methamphetamine purity fluctuated between 70 and 80 percent, while methamphetamine from Mexico was only 20 to 30 percent pure.

Texas Methamphetamine indicators were low but increasing. According to DEA, both Mexican and locally produced methamphetamine were available. 'Ice' was being sold in Houston by Mexican traffickers. According to street outreach workers, methamphetamine was readily available in Austin; many younger adults (age 25-30) smoked the drug, while most older adults injected it. Street outreach workers in Fort Worth reported that ice was 'on the streets.'

Honolulu, Los Angeles, Phoenix, San Diego, San Francisco, and Seattle CEWG representatives have their own "story to tell" about changes in methamphetamine indicators.

Honolulu On the basis of several indicators, Hawaii retains the title as the crystal methamphetamine capital of the United States. It remained the drug of choice on the islands. Purity approached 100 percent. Prices have remained relatively stable but varied according to type, with clear white methamphetamine being more expensive than the less processed brownish 'wash.' The mainland was the major source of the material used for reprocessing as crystal methamphetamine ('ice'). Evidence of increased availability was the regular closings of clandestine labs in the State. Los Angeles

Los Angeles Methamphetamine continued to make its presence known, both locally and regionally. The Los Angeles High Intensity Drug Trafficking Area (HIDTA) led all California HIDTAs in terms of clandestine lab seizures, with a total of 135 during the second quarter of 2002. Primary methamphetamine treatment admissions continued to climb and recently surpassed primary marijuana admissions in Los Angeles County. According to the California Department of Alcohol and Drug Program's 'First Annual Report to the Legislature,' methamphetamine was the drug of choice for 48 percent of the clients who received treatment in the State under the Substance Abuse and Crime Prevention Act of 2000 (a.k.a. Proposition 36) from July 1, 2001 to December 31, 2001.

Phoenix Methamphetamine indicators continued to increase. Ongoing DEA investigations showed no decrease in availability of methamphetamine in Arizona. It continued to be widely available throughout most of Arizona in the crude brownish Mexican form, with a purity range of 20 to 40 percent. It was also widely available in the more pure crystallized form referred to as 'ice' or 'glass' that has a much higher purity level, 95-99 percent. DEA estimated that approximately 30-40 percent of methamphetamine purchased recently was ice, with the remainder being Mexican methamphetamine. The DEA also reported that 145 clandestine methamphetamine laboratories were seized during the third and fourth quarters of 2002. The pseudoephedrine/ red phosphorous/iodine method was the manufacturing process reported in all seized laboratories. Each pound of methamphetamine results in 5 pounds of toxic waste and costs approximately $6,000 per lab to clean up.

San Diego The majority of Proposition 36 mandated referrals to treatment reported methamphetamine as their primary problem. As a result, males were overtaking females in treatment. Methamphetamine prices increased slightly and seizures of the drug at the San Diego/ Imperial County border increased 31 percent from 2000 to 2001, when 630.3 kilograms were seized.

San Francisco Ethnographic observers noted that the speed scene in San Francisco remained active in 2002, but less so than during the peak years of activity around 1997. Gay men no longer dominated the user population. While methamphetamine indicators were mixed, usage continued to be widespread, and risky injection practices among gay/bisexual men continued to be a major factor in HIV incidence.

Seattle Indicators of methamphetamine abuse have stabilized, including treatment admissions and manufacturing site seizures. However, the percentage of male arrestees in Seattle-King County testing positive (ADAM) for methamphetamine continued to increase. Provisional data for 2002 showed that 14.4 percent of arrestees tested positive for methamphetamine. This compares to 11 percent in 2001.

Across the coterminous United States, there were 14,923 methamphetamine ED mentions in DAWN in 2001 and 18,555 mentions of amphetamines, with a rate of 6 and 7 per 100,000 population, respectively. No significant change in mentions of either drug category was evident from 2000 to 2001. Together, these two drug categories accounted for 33,478 ED mentions in 2001, or approximately 5.2 percent of all mentions. Most (93 percent) amphetamine mentions were attributed to "amphetamine;" however, methamphetamine mentions were split among "crank" (13 percent), "methamphetamine" (65 percent), and "speed" (16 percent). As noted in the DAWN 2002 publication, it is not possible to estimate the accuracy of distinctions between amphetamine and methamphetamine mentions as reported in DAWN.

In 2001, the rate of methamphetamine ED mentions per 100,000 population was highest in San Francisco (39 mentions), followed by San Diego (27), Phoenix (21), Los Angeles (18), Seattle (18), and Minneapolis/St. Paul (12) (exhibit 22). Significant increases occurred in four areas--Atlanta, Los Angeles, Miami, and Minneapolis/St. Paul--while rates decreased in Newark and Seattle.

Rates of amphetamine ED mentions in 2001 were higher than those for methamphetamine in all areas except Los Angeles and Minneapolis/St. Paul, with the highest rate (50) being in San Francisco, up 121 percent from 2000. Significant increases in rates of ED amphetamine mentions from 2000 to 2001 also occurred in Baltimore (up 55.0 percent) and Phoenix (1.2 percent). As depicted in exhibit 22, the highest rates of amphetamine ED mentions tended to be in areas with the highest rates of methamphetamine mentions.

Exhibit 22. Rates of Methamphetamine and Amphetamine ED Mentions Per 100,000 Popluation by CEWG Area: 2001

1 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

DAWN trend data show significant increases in rates of ED methamphetamine mentions from 1994 to 2001, 1999 to 2001, and 2000 to 2001 in Atlanta, Miami, and New Orleans. The trend data on amphetamines show that ED mentions in this drug category increased in 13 CEWG areas from 1994 to 2001 and in 9 areas from 1999 to 2001 (with a slight decrease in Dallas). Significant increases in these two time periods continued from 2000 to 2001 in Baltimore and San Francisco, while decreasing slightly in Phoenix.

Across CEWG areas, primary admissions for abuse of methamphetamine and amphetamines are typically combined into the category of "stimulants." In 2001, primary admissions, excluding alcohol, for stimulants were highest in the following areas: Hawaii (49 percent), San Diego (47 percent), Seattle (16 percent), Los Angeles (15 percent), Colorado (15 percent), Minnesota (11 percent), Texas (9 percent), San Francisco (7 percent), St. Louis (5 percent), and Illinois (4 percent). Primary stimulant admissions in the other reporting areas ranged from zero in Baltimore to 2.4 percent (for methamphetamine) in Atlanta.

Of the six CEWG areas that reported separately on primary methamphetamine admissions in 2001, this abuser group accounted for 46.6 percent of admissions for illicit drug use in Hawaii, 45.0 percent in San Diego, 10.2 percent in Los Angeles, 5.9 percent in Denver, and for 0.3 and 0.7 percent, respectively, in Washington, DC, and Philadelphia.

Across ADAM/CEWG sites in 2001, the percentages of males testing methamphetamine-positive were highest in Honolulu, San Diego, and Phoenix, ranging from approximately 25 to 37 percent (exhibit 23). Not shown in the exhibit are seven sites where the percentages ranged from zero or near zero (Chicago, Detroit, Laredo, New Orleans, New York, and Philadelphia) to 1.7 percent (Dallas). Across the seven sites shown in exhibit 23, there were increases from 2000 in the percentages of males testing methamphetaminepositive. Most were small increases of less than 2 percentage points. The figure shown for Phoenix, however, represents a 6.2 percentage- point increase over 2000.

Exhibit 23. Percentages of Adult Male Arrestees Testing Methamphetamine-Positive by Site: 2001

SOURCE: ADAM, NIJ

Four of the seven ADAM/CEWG sites that reported data on adult female arrestees in 2001 reported more than 0.7 percent with methamphetamine-positive screens. However, as shown in exhibit 24, the percentages of women testing methamphetamine-positive were particularly high in Honolulu, Phoenix, and San Diego, ranging from approximately 32 to 37 percent. Compared with 2000, the proportion of women testing methamphetamine-positive increased more than 8 percentage points in Phoenix and San Diego, while decreasing 11 percentage points in Honolulu and 1 percentage point in Denver.

Exhibit 24. Percentages of Adult Female Arrestees Testing Methamphetamine-Positive in Four Sites: 2001

SOURCE: ADAM, NIJ

Club Drugs

The term "club drugs," as used here, includes methylenedioxymethamphetamine (MDMA or ecstasy); gamma hydroxybutyrate (GHB); gamma butyrolactone (GBL); and 1,4-butanediol.

MDMA

MDMA indicators increased in two CEWG areas (Atlanta and Texas), as shown in the quotes below. Atlanta, Minneapolis/St. Paul, and Phoenix report the presence of drugs other than MDMA in pills sold as ecstasy.

Atlanta The rate of MDMA ED mentions in Atlanta more than doubled between 2000 and 2001 (from 2 to 5 per 100,000 population). There is, of course, always speculation about what drugs are contained in tablets sold as ecstasy. Ethnographic data suggest that individuals with some experience in using ecstasy suspect everything from MDMA and speed to dextromethorphan (DXM) and heroin in such tablets. Some testing done by and DanceSafe confirms the presence of DXM and MDMA in many pills and, while several people maintain that pills contain heroin (also known as 'smacky ecstasy'), no local pills tested recently appear to have contained heroin.

Minneapolis/St. Paul MDMA abuse by young people in the metropolitan area continued to escalate, no longer limited to raves or nightclub settings. MDMA comes in small pills of different colors with various logos imprinted on them, or in capsules that typically sell for $20 each. Law enforcement seizures of MDMA submitted to area crime labs revealed that the exact content of the pills sold as ecstasy remained variable. Nearly 2,000 ecstasy pills seized by Minneapolis police actually contained a combination of MDMA, methamphetamine, and ketamine. MDA (3,4-methylenedioxyamphetamine), a chemical similar in effect to MDMA, was also being sold as ecstasy.

Phoenix According to a confidential source, there is a rumor in the rave community in Maricopa County that some of the ecstasy at raves was being laced with heroin and methamphetamine. The DEA reported that field drug tests on seized ecstasy might validate the rumor. The seized ecstasy tablets have been embedded with 'flying white dove' and 'HP,' for 'Harry Potter,' logos.

Texas Ecstasy ED mentions and treatment admissions increased. The 2001 ED data showed that only 6 percent of the mentions involved MDMA alone. The 2002 secondary school survey showed that lifetime ecstasy use was 8.6 percent, up from 4.5 percent in 2000; pastmonth use in 2002 was 3.1 percent, compared with 1.9 percent in 2000. Adult treatment admissions for a primary, secondary, or tertiary problem with ecstasy increased from 63 in 1998 to 97 in 1999, to 141 in 2000, to 252 in 2001, and to 290 through October 2002. A similar increase occurred among adolescent admissions: 18 in 1998, 17 in 1999, 58 in 2000, 97 in 2001, and 145 through October 2002. Among these particular client groups, 22 percent of adults and 26 percent of youth reported ecstasy as their primary problem.

MDMA use often does not appear in traditional data sources (e.g., treatment and ADAM) because of the different ways it is used (often in combination with other substances) and the types of people who use this drug.

Based on community-level data from local sources, most CEWG members found that MDMA use was increasing and becoming more widespread. Also, as will become apparent from the following excerpts, the use of this drug had spread beyond the rave and nightclub venue, to different ethnic groups, high school and college students, and gay populations, and some CEWG areas reported increases in seizures of MDMA.

Atlanta While raves and house parties were never a large presence in Atlanta, they and some particular clubs seemed once to be the focal point of most ecstasy use. That trend is changing as more people talk about using the drug in other settings, such as at home either with small groups of friends or just with a sex partner. Two fairly distinct camps appear to be emerging, those who feel ecstasy is very sensual but inhibits their ability to actually have sex (much the way some people talk about methamphetamine) and those who use it specifically because, for them, it enhances their sexual experience and ability (much the way some people refer to drugs like Viagra). Also, while the majority of users simply swallow ecstasy pills, there are a few who have reported at least intermittently injecting it. Currently, this does not appear to be a trend that is catching on, but it does bear watching as it has numerous public health consequences.

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 that ecstasy--or drugs sold as ecstasy--was widely available among high school and college students. Individuals with connections to suppliers or producers reported prices as low as $12-$15 per pill. MDMA continued to be used predominantly by White youth, but there were increasing reports of ecstasy use from African-Americans in their twenties and thirties who have been involved in club scenes. The Illinois State Substance Abuse Agency began reporting treatment data related to club drugs for the first time in FY 2002, when there were 50 such admissions; 68 percent were male and 74 percent were White.

Denver Data from the 2002 Colorado Youth Survey showed that lifetime MDMA use was reported by 0.7 percent of 6th graders, 1.1 percent of 7th graders, 3.0 percent of 8th graders, 4.4 percent of 9th graders, 5.2 percent of 10th graders, 10.8 percent of 11th graders, and 9.8 percent of 12th graders. In a treatment survey sample of 782, 267 (34 percent) reported lifetime use of ecstasy, with 4.5 percent having used the drug in the prior 30 days. The average age of the users was 17.3 years, and the average age of first use was 15.9 years. The DEA reported that ecstasy has emerged as a popular drug in the Rocky Mountain Region. It was readily obtainable by individuals at raves, nightclubs, strip clubs, or private parties. The traffickers were typically White and in their late teens or twenties and obtained their MDMA from Las Vegas, Nevada, and various cities in California and on the east coast, with source connections in Europe.

Detroit There have been many anecdotal reports of widespread and increasing use of ecstasy since 1997, but the drug rarely appeared in traditional indicators identifying abuse. ED mentions have increased, and a few cases appeared in treatment and poison control center data. Ecstasy, sold in various colored and often stamped pill forms, has been seized throughout Michigan. Sources remain Western Europe and Canada. Projections for 2002 are that the U.S. Customs Service in Detroit will seize 1.2 million ecstasy pills by the end of the year.

Los Angeles Despite a recent significant decline in the number of MDMA (ecstasy) and GHB mentions recorded during drug-related emergency department episodes, anecdotal evidence from a variety of local sources continued to lend support to the claim that the use of club drugs is spreading in Los Angeles County.

New York The Street Studies Unit continues to report the availability of MDMA in many areas of the city. Since ecstasy (which is not always MDMA) is sold by sellers of other types of drugs, the profile of sellers is expanding across racial and social class boundaries. There are indications that the distribution and use of club drugs are becoming more common in non-White communities. Club drug users tend to be multiple substance abusers who use such substances as alcohol, marijuana, cocaine, and other club drugs.

Philadelphia Focus groups in the spring and autumn of 2000 described MDMA as highly potent and used in combination with heroin, alcohol, and/or cough syrup. Focus groups since the spring of 2001 reported that MDMA is used in combination with marijuana and LSD, which better describes use in clubs or raves. The autumn 2002 focus groups described the users as evenly split by gender and ranging in age from teenagers to people in their early twenties.

St. Louis The rave scene has become quite popular in St. Louis, where ecstasy was freely available. Most of the users were teenagers or young adults. Most of the users in dance clubs and at universities were in the 20-25-year-old age group. While reported use of MDMA or 'X' in high school students was frequent, no indicator quantified use in this age group. Toxicology reports showing high levels of ecstasy were rare. Most of the reports about high levels of MDMA abuse were anecdotal or were part of a polydrug user's history. Public treatment programs reported no admissions for MDMA. The private treatment programs that were queried reported MDMA as part of a polydrug abuser's history in less than 2 percent of their treatment admissions. As part of the screening of a cohort of known MDMA users, a local researcher reported that hepatitis C was at high levels in this group. This hepatitis rate may be related to the polydrug use history of these participants.

San Diego MDMA (and GHB and ketamine) continued to figure prominently in local media. However, there continued to be little hard evidence in the typical quantitative indicator sources. In 2000, the County Medical Examiner reported two MDMA-related deaths; the number doubled to four in 2001. Local experts believe that MDMA and other club drugs will be the next big problem in San Diego and are convinced that club drug use is already widespread. They pointed to seizures and to the largest MDMA bust in the country, which occurred in San Diego County in 2001.

San Francisco In a sample of 356 gay/bisexual men at late-night venues, 36 percent reported using MDMA during the prior 3 months.

Seattle MDMA indicators remain elevated. The Public Health Clinic serving Seattle and King County reported a relationship between MDMA use and increased risk for sexually transmitted diseases among men who have sex with men (MSM).

Washington, DC Ethnographic reports suggest that MDMA remained prevalent in the District's gay and nightclub scenes. Law enforcement officials noted that drug pushers, who sell other drugs in street markets, have started distributing MDMA. New levels of violence are associated with the distribution of MDMA.

After rising sharply in 13 CEWG areas from 1994 to 2001, and in 14 CEWG areas from 1999 to 2001, rates of ED MDMA mentions per 100,000 population tended to decline or stabilize in 15 areas from 2000 to 2001.

In 2001, the rate of ED MDMA mentions in eight CEWG areas did not differ from that found for the coterminous United States--2 per 100,000 population. There was no significant change from 2000 in four of these areas: Dallas, New York, St. Louis, and San Diego. Significant decreases from 2000 to 2001 were reported in the other four: Seattle (17 percent), Los Angeles (19 percent), Denver (39 percent), and Chicago (42 percent).

In 13 CEWG areas, the rate of ED MDMA mentions in 2001 exceeded that for the coterminous United States, ranging from 3 per 100,000 population in 8 areas to 10 in San Francisco. Rates for these 13 CEWG areas are depicted in exhibit 25.

GHB

Across the coterminous United States, the rate of ED GHB mentions was 1 per 100,000 population, while the estimated number of mentions was 3,340. There was no significant change from 2000 to 2001 or from 1999 to 2001, following a dramatic increase from 1994 to 2001 (from 56 to 3,340 mentions, an increase of 5,864 percent). CEWG areas accounted for all but one GHB mention.

Across CEWG areas in 2001, the highest rates of ED GHB mentions were in San Francisco (10), New Orleans (6), Dallas (4), and Minneapolis/St. Paul (3). Rates in these four areas did not change significantly from 2000. There were significant decreases in ED mentions in six CEWG areas, where rates were 1 or 2 per 100,000 population in 2001: Atlanta, Chicago, Denver, Los Angeles, Miami, and Seattle, with percentage decreases ranging between 23 and 69 percent. Only Baltimore, with a rate of zero, reported an increase in ED GHB mentions between 2000 and 2001 (141 percent). The highest estimated numbers of ED GHB mentions in 2001 were in San Francisco (158), Dallas (128), Chicago (104), Philadelphia (90), Atlanta (84), Los Angeles (83), New Orleans (72), and Minneapolis/St. Paul (68). The lowest numbers of ED GHB mentions in 2001 were in San Diego (3) and Baltimore (7).

Of the 870 GHB ED visits for the coterminous United States in 2001, 26 percent involved GHB only. The most frequently mentioned other drugs were alcohol (54 percent), marijuana (14 percent), and MDMA (12 percent). Other GHB indicators varied within and across CEWG areas, as is apparent in the quotes that follow.

Exhibit 25. CEWG Areas Where the Rate of ED MDMA Mentions Exceeded 2 per 100,000 Populations in 2001

SOURCE: Adapted from DAWN, Office of Applied Studies, SAMHSA

Chicago Compared with other club drugs, overdoses were more frequent with GHB, especially when it was used in combination with alcohol. GHB is sold as a liquid, in quantities ranging from drops (from a dropper used at raves or parties) to capfuls. Prices for a capful have been reported at $10-$25.

Denver In 1999, the number of GHB calls jumped to 92 at the Rocky Mountain Poison and Drug Center, up from 1-6 calls per year since 1994. According to the 2002 Colorado Youth Survey, lifetime GHB use was reported by 0.4 percent of 6th graders, 0.6 percent of 7th graders, 1.2 percent of 8th graders, 1.3 percent of 9th graders, 1.5 percent of 10th graders, 1.4 percent of 11th graders, and 1.2 percent of 12th graders. In ADAD's treatment survey, 73 of 782 clients (10 percent) reported lifetime use of GHB, with 0.5 percent having used in the prior 30 days. The average age of the users was 17.8 years, and the average age of first use was 16.1. The DEA reported that GHB is increasing in popularity in Colorado and was readily available at raves, nightclubs, strip clubs, and private parties. The price is $5-$10 per dosage unit (i.e., one bottle capful).

Detroit GHB use has been primarily at nightclubs (use appears to be more confined recently to gay scenes) and private parties. ED GHB mentions and poison center case reports declined since 1999.

Newark GHB use is still rare in Newark.

St. Louis GHB use has increased in the St. Louis area. Because it is a depressant, its use with alcohol and its unpredictable purity present users with major health risks. GHB is often sold in nightclubs for $5 per capful or $40 per ounce. GHB education efforts are directed towards ED personnel, who often see the users initially.

San Diego GHB still figured prominently in local media. The county ME reported two GHB-related deaths in 2000 and two in 2001.

San Francisco In a sample of 356 gay/bisexual men at late-night venues, 18 percent reported GHB use during the prior 3 months.

Seattle GHB indicators remained elevated.

Texas GHB, GBL, and similar precursor drugs remained a problem, particularly in the Metroplex area, with a comparatively high rate of ED mentions in 2001 (4.1 per 100,000 population). Treatment clients with a primary, secondary, or tertiary problem with GHB, GBL, or 1,4-butanediol have increased. In 1998, 2 adults were admitted, compared with 17 in 1999, 12 in 2000, 19 in 2001, and 29 through October 2002. Of this group in 2002, 28 percent had a primary problem with GHB.

Phencyclidine

PCP abuse indicators are low in most CEWG areas, although indicators increased in several areas. A common form of PCP abuse, as apparent in the quotes that follow, is as an additive to marijuana joints or blunts.

Chicago PCP ED mentions have increased, although not significantly. Ethnographic reports suggested that PCP use in Chicago has remained constant and that the drug could be found in all areas of the city. PCP is typically smoked and is sold in various forms. 'Leaf' (also known as 'love leaf') is a moist, loose, tobacco-like substance sprayed with PCP and wrapped in tin foil. Some say the substance is marijuana, others say it looks and tastes like cigarette tobacco, but most often it is said to be parsley. 'Sherm sticks' typically are cigarettes or small cigars dipped in PCP, drained, and dried. 'Wet sticks' are said to be cigarettes dipped in PCP and embalming fluid. PCP was also said to be sold in sugar cubes. Liquid PCP ('water') was said to sell for $120 a vial.

Minneapolis/St. Paul Joints dipped in formaldehyde or embalming fluid, which is often mixed with PCP, are known as 'wets,' 'amp,' 'wet sticks,' or 'wet daddies.' They are easily distinguished by their pungent, unpleasant, chemical odor. PCP can also be injected or snorted. In Minneapolis, 3.3 percent of male arrestees tested positive for PCP in 2001, compared with 1.8 percent in 2000. ED mentions of PCP rose insignificantly to 24 in 2001, from 20 in 2000.

Newark PCP, as a primary, secondary, or tertiary drug among treatment admissions increased in the Newark area and statewide in 2001.

Philadelphia PCP began gaining popularity as an additive to blunts in 1994. Users describe its effects as making them hallucinate, feel 'invincible,' 'crazy,' 'numb,' or 'violent.' PCP has become easier to obtain than ever. PCP was more commonly available on mint leaves for use in lacing blunts. Less commonly, PCP in liquid form was available and was used by having cigarettes dipped into the liquid, a method referred to as 'sherms' or 'dip sticks.'

St. Louis PCP has been available in limited quantities in the inner city and has generally been used as a dip on marijuana joints. While PCP was not seen in quantity, it remained in most indicator data, including ED mentions, police exhibits, and as a secondary drug in ME data. Most of the users of this drug in the inner city were African- American. PCP ED mentions increased significantly from 2000 to 2001 for females and for those age 18-25 and 35-44. However, the total number of ED mentions remained relatively low at 110.

Seattle Slang terms for various combinations of PCP with other drugs include 'shermans,' 'wets,' 'fry,' and embalming fluid. Embalming fluid is used to dissolve the PCP. During 2001, 25 percent of the PCP ED mentions used marijuana.

Texas Texas Poison Control Centers' cases, where such terms as 'fry,' 'amp,' or 'PCP' were mentioned or abuse of formaldehyde was indicated, increased from 170 in 2000 to 211 in 2002 as of the end of September. The average age of these cases was 21.8. Adult and adolescent admissions for a primary, secondary, or tertiary problem with PCP also increased. Such admissions among adults rose from 102 in 1998 to 174 in 2001, and totaled 178 through October 2000; adolescent admissions increased from 62 in 1998 to 76 in 2001, and totaled 35 in the first three quarters of 2002. In 2002, 71 percent of this adult group were male as were 83 percent of the youth client group.

In 2001, the rate of PCP ED mentions in the coterminous United States was 2 per 100,000 population, the same as in 2000. The number of mentions was 6,102, with all but 3 of the mentions being in the 20 CEWG areas included in DAWN. The two most prominent age groups were 18-25 (38.9 percent) and 35 and older (30.9 percent). African-Americans dominated (42.9 percent), followed by Whites (33.7 percent), and Hispanics (14.5 percent); approximately 9 percent were in the "unknown" category.

In CEWG areas in 2001, PCP ED rates per 100,000 population were highest in Philadelphia (17), Washington, DC (13), and Los Angeles (12). Rates increased significantly from 2000 to 2001 in Philadelphia (up 40.5 percent) and Washington, DC (56.2 percent). The rate also increased significantly in Boston (from zero to 1 per 100,000 population). Rates were 5 in St. Louis and San Francisco and 6 in Seattle. In other areas, the rates of PCP ED mentions ranged between 1 and 3, with no significant change from 2000.

In the ADAM program in 2001, small percentages of adult male arrestees tested PCP-positive in six CEWG sites: Philadelphia (6.9 percent), Chicago (5.1 percent), Minneapolis (3.4 percent), Seattle (l.8 percent), and New York and Phoenix (each 1.5 percent). Across CEWG areas, only New York reported any positive PCP urine screens among female adults, at 1.5 percent.

PCP is reportedly contained in many marijuana joints and blunts. Joints and blunts dipped in embalming fluid are popular in many areas. "Embalming fluid" has long been a slang term for PCP. "Water" and "wets" are also terms used to describe joints or cigarettes dipped in embalming fluid. The NDIC noted that some patients who reported smoking joints or cigarettes dipped in embalming fluid exhibited symptoms identical to PCP intoxication.

Benzodiazepines

Benzodiazepines, among the most widely prescribed medications, are frequently used by substance abusers in combination with other substances. This family of depressants is used therapeutically for such purposes as inducing sleep and relieving anxiety. In general, benzodiazepines act as hypnotics in high dosages, as anxiolytics in moderate dosages, and as sedatives in low dosages. Benzodiazepines with longer durations of action include alprazolam (Xanax), chlordiazepoxide (Librium), clorazepate (Tranxene), diazepam (Valium), and lorazepam (Ativan). Flunitrazepam (Rohypnol) produces diazepam-like effects.

Benzodiazepine indicators increased in most CEWG areas. Abuse of benzodiazepines is particularly high among heroin and cocaine abusers. Alprazolam, is also popular among polydrug users.

Atlanta Benzodiazepines accounted for the largest portion of psychotherapeutic agent ED mentions in Atlanta, with a rate of 32 mentions per 100,000 population. Within this category, alprazolam, better known as Xanax, had the highest rate in 2001 (9), down from a high of 14 in 1998. Ethnographers continually found that individuals were using various depressants as part of a pattern of polydrug use. Xanax, Valium, and Dilaudid were mentioned most often.

Chicago Consistent with ED mentions, ethnographic reports indicated that alprazolam appeared to be the benzodiazepine most readily available on the street, followed closely by clonazepam and lorazepam, with variations in different parts of the city.

Newark Benzodiazepines remained the fifth most abused drug in Newark, after alcohol, heroin, cocaine, and marijuana.

New York According to the Street Studies Unit, one of the most popular pills on the street is alprazolam (Xanax). Called 'footballs,' Xanax pills sell for $5 each. The majority of pill selling locations are within a two-block radius of treatment programs.

St. Louis Private treatment programs often provided treatment for benzodiazepine, antidepressant, and alcohol abusers.

Texas The number of ED mentions of alprazolam (Xanax), diazepam (Valium), and clonazepam (Klonopin) was rising in Dallas emergency rooms. The proportion of Xanax exhibits as a percentage of benzodiazepine exhibits identified by the DPS labs was also increasing. The 'white bars' or 'handle bar' 2-milligram Xanax pills that are scored can be easily broken into pieces and sold for $4-$5 per pill. The blue 1-milligram football-shaped Xanax sells for $2 per pill.

Across the coterminous United States in 2001, DAWN ED mentions of benzodiazepines totaled 103,972 and represented 9 percent of all ED drug mentions. The mentions increased 14 percent from 2000 to 2001, continuing the significant increases found between 1994 and 2001 and 1999 and 2001. The most frequently mentioned benzodiazepines in 2001 were alprazolam (25,664 mentions), clonazepam (19,117), lorazepam (11,902), diazepam (11,447), and temazepam (2,637). Mentions of alprazolam increased significantly in all time periods tested (1994, 1999, 2000-2001), as did those for benzodiazepines- NOS. In 2001, the rate of benzodiazepine ED mentions was 41 per 100,000 population, up 11 percent from 2000.

Of the 103,972 DAWN benzodiazepine ED mentions in 2001, 99.8 percent were reported from CEWG areas. Mentions increased significantly in 11 CEWG areas, with the numbers ranging from a low of 644 in Denver to a high of 3,388 in Boston. Rates of benzodiazepine ED mentions per 100,000 population also varied by CEWG area, as shown in exhibit 26, and increased significantly in 9 areas from 2000 to 2001.

Exhibit 26. Rates of Benzodiazepine ED Mentions Per 100,000 Population by CEWG Area: 2001¹

1 One asterisk (*) indicates a statistically significant (p <0.05) increase from 2000 to 2001; two asterisks (**) indicate a significant decrease for the 2000-2001 time period. SOURCE: Adapted from DAWN, Office of Applied Studies, SAMHSA

Percentage increases in benzodiazepine ED rates were greatest in Detroit (49.9 percent), Baltimore (30.9 percent), San Francisco (29.3 percent), Newark (29.2 percent), and Boston (23.3 percent)--all areas with high rates of heroin ED mentions in 2001. The increases from 2000 to 2001 in Baltimore, Dallas, Minneapolis/St. Paul, and Newark continued the significant trends from 1994 and 1999. Across all three time periods tested, rates of benzodiazepine ED mentions remained stable only in Los Angeles, New Orleans, St. Louis, and Washington, DC.

Canada (CCENDU)

A representative of the Canadian Community Epidemiology Network on Drug Use (CCENDU) presented an update on the CCENDU system and the most recent data reported on drug abuse patterns and trends in Canada. Chaired by the Canadian Centre on Substance Abuse, Canada's national addictions agency, CCENDU is a multilevel collaborative project that collects and disseminates quantitative and qualitative information on drug abuse. The 2001 Uniform Crime Report Survey showed an increase in the rate of total drug offenses from 286 per 100,000 population in 2000 to 296 in 2001. In 2001, cannabis charges represented the majority of drug offenses for adult males (71 percent) and adult females (62 percent). Drug abuse patterns differed by area. For example, based on indicators, crack (injection and smoking) was the illicit drug most used in Toronto. An increase in methamphetamine indicators in Vancouver may be related to the methamphetamine problem in the United States in Washington and California. In Halifax, 80 percent of the treatment clients (in a 2001 survey) reported using cocaine, benzodiazepines, and/or opiates. It was reported that there was a strong presence of rave drugs in St. John's, compared with 3 years ago.

Canadian College Substance Use Survey

The Director of the Life Course Studies Centre for Addiction and Mental Health in Toronto, Ontario, presented findings from a 1998 substance use survey of college students in Canada. Comparisons were made between the Canadian and American college (1999) survey findings. The Canadian national survey included a sample of 16 universities offering undergraduate degrees. The survey, conducted by mail, included 7,800 respondents. Lifetime prevalence was significantly higher in the United States than in Canada for methamphetamine (8.1 vs. 5.2 percent), cocaine (6.7 vs. 3.8 percent), and MDMA (8.9 vs. 4.2 percent), while hallucinogen use was higher in Canada (18.3 vs. 13.3 percent).

Central Asia

In 2000-2001, the United Nations International Drug Control Programme regional office in Central Asia, with technical support from the Global Assessment Programme on Drug Abuse, implemented a project to assist national counterparts in assessing the nature and extent of drug problems in the former Soviet republics of Kyrgyzstan, Kazakhstan, Tajikistan, Turkemenistan, and Uzbekistan. Multimethods and data sources were used to develop a comprehensive picture of drug use problems in each country. Existing health, drug treatment, and law enforcement data were analyzed to obtain initial information and as a proxy indicator for a time series of analysis of changing trends in drug use. Interviews were held with more than 100 key informants (e.g., doctors, law enforcement officials, community leaders) in 5 urban and rural locations in each country. Snowball sampling was used to select at least 100 problem drug users in at least 2 locations in each country. Additional indepth interviews were conducted with 200 injection drug users and with 60 drug users in each country in prison settings to assess patterns of drug use and other issues. Multiplier techniques were also used to calculate national estimates of drug use.

Estimates of the rates of problem drug users per 100,000 population varied across 4 countries, with the estimated rate being highest in Kyrgyzstan (1,644-2,054), followed by Kazakhstan (1,110-1,255), Tajikistan (734-897), and Uzbekistan (262-367). All countries showed increases in rates of drug users treated from 1992 to 2000.

Central Asia is increasingly used as a transit point for heroin trafficking from Afghanistan to European markets. The main transition in these Central Asian countries has been from the traditional smoking of opium or cannabis to the injection of heroin and other opiates among younger age groups. The sharing of injection paraphernalia has contributed significantly to the spread of bloodborne diseases, including the human immunodeficiency virus (HIV) infection.

Egypt

An investigation into the dynamics of demand for drugs within the Greater Cairo area of Egypt was conducted by the Behman Hospital through intensive interviews with male drug users in inpatient treatment facilities. The study was sponsored by the United Nations International Drug Control Programme and the Regional Office for the Middle East and North Africa.

The most popular types of drugs were heroin, flunitrazepam (marketed in Egypt as Rohypnol), and other opiates. The low-income group used inexpensive drugs, such as benzodiazepines, hashish, and bango, in large quantities. A high percentage of the illicit drug addicts used psychoactive drugs as a substitute for narcotic drugs.

The majority of drug users had been using addictive drugs for a period longer than 6 years, indicating that treatment for addiction was not effective, or that addicted persons were not willing to be treated. For safety reasons, the retailer was considered the key source of drugs. Low-income users dealt with wholesalers to take advantage of price discounts and to generate income through distributing drugs on behalf of the wholesaler. The low-income group relied on illegal and informal sources of income in obtaining drugs.

The majority of addicted young people belonged to the upper-middle socioeconomic class and had a relatively high level of education. The main reasons for addiction were social, such as family problems. Young addicts were characterized by the following:

• They were heavy users of bango, benzodiazepines (other than flunitrazepam), and flunitrazepam
• They abused psychoactive drugs as substitutes for narcotic drugs
• Frustration, trial, and pleasure-seeking were the key reasons for using drugs
• They acquired drugs primarily from retailers and friends, preferring to deal with safe sources

Israel

Researchers at Ben Gurion University of the Negev Be'er Sheva in Israel are in the process of establishing a substance abuse surveillance and early warning system in Israel. The project is financed by the U.S. Agency for Economic Development (USAED) and the Middle East Regional Cooperative Program.

Initially it was difficult to obtain approval from government authorities to collect drug abuse indicator data. One of the first studies was structured to obtain data on the perceptions of youth service workers who work with juvenile offenders in the National Office of Youth Probation Services. Eighty-nine workers, with a cumulative caseload of 7,000 juveniles, were interviewed. According to the workers, about 37 percent of the youth had alcohol problems, and 56 percent were binge drinkers; marijuana was considered the most problematic substance. The information was used to assess the training needs of workers.

Mexico (SISVEA)

Mexico's Epidemiologic Surveillance System of Addictions (SISVEA), a network of institutions specializing in addiction services and research, operates in 25 Mexican cities; one-half 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 nongovernment 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 NCG 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.

Palestine

The Substance Abuse and Research Center (SARC-Palestine) conducted a study of high school students (N=1,034) in 26 Palestine schools (14 boys' and 12 girls' schools). A field team was trained, and data were collected using self-administered questionnaires. The data were entered twice on two computers and comparisons were made. Approximately 21 percent of the girls and 15 percent of the boys reported observing youth taking tablets a few times. Nine percent of the boys and 7 percent of the girls had observed youth using substances. Most students (90 percent of girls and 80 percent of boys) felt that their friends would object to them using heroin. However, only 43 percent of the girls and boys indicated that their friends would object "much" if they used hypnotics, tranquilizers, and/or central nervous system stimulants without prescription. More than one-half (58 percent) of the girls and 43 percent of the boys reported that it was easy or very easy to get these drugs. Nine percent of the boys and 5 percent of the girls indicated that it was easy or very easy to obtain heroin.

South Africa (SACENDU)

The South African Community Epidemiology Network on Drug Use (SACENDU) Project is an alcohol and other drug (AOD) sentinel surveillance system operational in Cape Town, Durban, Port Elizabeth (PE), Mpumalanga, and Gauteng (Johannesburg/Pretoria). The system monitors AOD use trends and associated consequences from multiple sources. Data are collected from over 50 specialist treatment centers, psychiatric hospitals, mortuaries, trauma units, and the police (SA Narcotics Bureau [SANAB], Organized Crime Units [OCU], and Forensic Science Laboratories [FSL]). Other data sources (e.g., community studies) are included when available.

Use of cannabis ("dagga") and Mandrax (methaqualone) alone or in combination ("white-pipes") continues to be high. Across sites, between 16 percent (Mpumalanga) and 49 percent (PE) of patients in specialist treatment centers had used cannabis and/or Mandrax as their primary drug of abuse. There has been a steady increase in treatment demand for cannabis-related problems over time in Cape Town, Durban, and Gauteng, and for Mandrax-related problems in Cape Town. Across sites, cannabis is the most prominent drug of abuse among patients younger than 20 (from 47 percent in Cape Town to 64 percent in Gauteng). In a school survey of five primary schools in Cape Town, almost 9 percent of learners had tried cannabis and over 2 percent had tried Mandrax. More than one-third of out-of-school youth age 12-26 in northern Kwa-Zulu Natal (KZN) reported lifetime use of cannabis, and a similar percentage of rave party attendees interviewed in Gauteng in September 2002 reported weekly use of cannabis.

The proportion of arrests for dealing in cannabis has decreased over time in Cape Town, Durban, and Gauteng, but increased substantially in PE in the first half of 2002 (to 55 percent of arrests). In PE, SANAB/OCU seized 695,093 kilograms of cannabis. With regard to Mandrax, the major change has been an increase in the proportion of arrests for dealing in Durban (to 64 percent of all arrests). Increased seizures of Mandrax were reported by SANAB in Gauteng (1.8-milligram tablets).

The increases in treatment demand for cocaine-related problems over time reported earlier for Cape Town, Durban, and Gauteng have not continued, and there has been a leveling off in treatment demand. Over time, there has been a dramatic increase in treatment demand for heroin as a primary drug of abuse in Cape Town and Gauteng, but this, too, appears to have stabilized. Treatment demand for ecstasy, LSD, or speed (methamphetamine) as primary drugs of abuse is low. These drugs more often appear as secondary drugs of abuse. The abuse of over-the-counter and prescription medicines such as slimming tablets, analgesics (especially products containing codeine), and benzodiazepines (e.g., diazepam and flunitrazepam) continues to be an issue across sites. Many patients report these substances as secondary drugs of abuse. Various sources reported increased availability and use of the synthetic stimulant methcathinone (produced from ephedrine) in Gauteng and Durban. It is sniffed/snorted and is known as "cat."

Judy Ball, Ph.D., M.P.A., Project Director, SAMHSA, and Lori Ducharme, Director of DAWN Facility Relations, Westat, provided CEWG members with an overview of the redesign of DAWN emergency department and mortality systems, inviting support of CEWG members in the effort. The process has begun through recruitment of communities and building on community leadership. The initiatives will be launched on January 1, 2003 and phased in through 2006.

The new DAWN ED system will cover the entire Nation by 2006, adding at least 27 metropolitan statistical areas (MSAs) to the current 21. The stratified probability sample will include about 900 short-term, general, non-Federal hospitals that operate 24-hour emergency departments. New data collection forms have been approved, the definition of a "case" has been expanded, all ages will be covered, and mentions will be expanded to include six drugs and alcohol. Health information currently lacking in DAWN will be gathered. New cases will include, for example, underage drinking; drug misuse; malicious poisoning; and adverse effects associated with prescription and over-the-counter drugs. Data will be collected from retrospective review of medical charts. Trained reporters will submit data electronically; the system will alert them if any entries represent inconsistent data. These and other changes will improve the quality of DAWN data. Improvements in precision of the ED estimates are expected based on the expanded sample. ED data prior to 2002 will not be comparable to the new data; thus, new trends will begin in 2003.

The DAWN mortality system will also be revised. All jurisdictions in the 48 target areas will be recruited, rather than a nonrandom subset (as is currently the case). Selected statewide systems will be added.

For the first time, the DAWN mortality and morbidity systems will be linked. Electronic reporting of the two data systems is expected to be fully functional by February 2004.