# Presentation: 235019

## National Estimates from the Drug Abuse Warning Network

- CAPT Kathy Poneleit
- United States Public Health Service
- Office of Applied Studies
- Substance Abuse & Mental Health Services Administration
- November 13, 2008
- _http://DAWNinfo.samhsa.gov_

## Today's Agenda

- No conflicts of interest
- Overview of DAWN
- Key findings from 2007
- Nonmedical use of opiates/opioids
- 2004-2007 comparisons
- Extended- vs. immediate-release oxycodone
- Extended- vs. immediate-release morphine

## DAWN Survey Design

- Stratified probability sample of hospitals
- Short-term, general, non-Federal hospitals with 24-hour emergency departments (EDs)
- National estimates account for:
- Sample design
- Unit nonresponse
- Partial nonresponse in responding hospital

## National Estimates

- Oversample areas (urban) +
- Remainder area (urban & rural)

## Source of DAWN Estimates, 2004-2007

|  | 2004 | 2005 | 2006 | 2007 |
| --- | --- | --- | --- | --- |
| Eligible hospitals | 4,505   | 4,549 | 4,568 | 4,575 |
|      Sample of hospitals | 556 | 562 | 544 | 542 |
|      Responding hospitals | 220 | 224 | 205 | 207 |
|      Response rate | 39.6 | 39.9 | 37.7 | 38.2 |
| Drug-related ED visits | 2,537,722 | 3,009,025 | 3,441,855 | 3,998,228 |
| Drugs reports | 4,047,135 | 4,624,455 | 5,384,817 | 6,247,718 |

**Notes:**
Response rate responding/issamped hospitals 

Design weighted iss 24-26%
Weighted response is 24-26%

## DAWN Data Collection:  Retrospective Review of Medical Records

- Source:  DAWN, 2007 data, 11/11/2008

**National estimates**

**Charts reviewed 10,038,897**

**Cases found 375,031**

**Drug-related**

**ED visits **
**reviewed**

**ED visits **
**not reviewed**

## Analysis Domains

## Definition:  Nonmedical Use of Pharmaceuticals

- Based on retrospective chart review
- Exceeded prescribed or recommended dose
- Used drugs prescribed for another
- Malicious poisoning
- Substance abuse
- Excludes drug-related suicide attempts
- Includes suicide ideation, plan, gesture

## Drug-Related ED Visit Rates, 2004-2007

- Source:  National estimates from DAWN, 2004-2007

- No significant change

- 2006 vs. 2007

**Notes:**
The bars are in groups of 4 which represent sequentially the years 2004-2007

- Oxycodone
- Controlled and Immediate Release

## Nonmedical Use of Pharmaceuticals, Selected Opiates/Opioids, 2007

- Source:  National estimates from DAWN, 2007

- * Single- & multi-ingredient formulations

**Notes:**
Starting with illicit drugs:

Here the confidence intervals help you see when differences are not statistically significant.
If the confidence intervals overlap, the estimates may not be different, such as cocaine & marijuana.
CIs also help you visualize the impact of sampling error.  Some estimates are not very precise.

Cocaine:  67,429 – 184,413

Heroin:  31,369 – 63,839

Marijuana:  39,067 – 120,259

Stimulants:  20,860 – 64,216

Amphetamines – about 3⁄4 from toxicology findings
Methamphetamine
When drug screen tests only for amphetamines as a class, amphetamine positive could mean amphetamine or methamphetamine.

## Nonmedical Use of Pharmaceuticals, Selected Opiates/Opioids, 2007

- Source:  National estimates from DAWN, 2007

- * Single- & multi-ingredient formulations

**Notes:**
Starting with illicit drugs:

Here the confidence intervals help you see when differences are not statistically significant.
If the confidence intervals overlap, the estimates may not be different, such as cocaine & marijuana.
CIs also help you visualize the impact of sampling error.  Some estimates are not very precise.

Cocaine:  67,429 – 184,413

Heroin:  31,369 – 63,839

Marijuana:  39,067 – 120,259

Stimulants:  20,860 – 64,216

Amphetamines – about 3⁄4 from toxicology findings
Methamphetamine
When drug screen tests only for amphetamines as a class, amphetamine positive could mean amphetamine or methamphetamine.

## Classification of Oxycodone Reports

- Controlled release (CR)
- OxyContin (99%)
- Alternate terms:
- Generic OxyContin
- Teva OxyContin
- Impax OxyContin
- Oxycodone CR
- Oxycodone ER
- Oxycodone SR

- Immediate release (IR)
- acetaminophen-oxy
- e.g., Percocet (92%)
- aspirin-oxy
- e.g., Percodan
- ibuprofen-oxy
- e.g., Combunox
- oxycodone
- e.g., Roxicodone

## Classification of Oxycodone Reports (cont'd)

- Unknown release type (UK)
- Oxycodone (95%)
- alternate terms:
- Free oxycodone
- M-Oxy
- Oxycodone hydrochloride
- Oxycodone metabolites

## Nonmedical Use of Pharmaceuticals, Oxycodone, by Release Type, 2004-2007

- Source:  National estimates from DAWN, 2004-2007

**Controlled**

**Immediate**

**Unknown**

**Notes:**
Starting with illicit drugs:

Here the confidence intervals help you see when differences are not statistically significant.
If the confidence intervals overlap, the estimates may not be different, such as cocaine & marijuana.
CIs also help you visualize the impact of sampling error.  Some estimates are not very precise.

Cocaine:  67,429 – 184,413

Heroin:  31,369 – 63,839

Marijuana:  39,067 – 120,259

Stimulants:  20,860 – 64,216

Amphetamines – about 3⁄4 from toxicology findings
Methamphetamine
When drug screen tests only for amphetamines as a class, amphetamine positive could mean amphetamine or methamphetamine.

## Oxycodone, CR vs. IR – All Visits

- Source:  DAWN estimates for the U.S., 2004-2007

- 2006 vs. 2007

- No significant change

**2004**

**2005**

**2006**

**2007**

## Oxycodone, CR vs. IR – Medical Use

- Source:  DAWN estimates for the U.S., 2004-2007

- 2006 vs. 2007

- No Significant change

**2004**

**2005**

**2006**

**2007**

## Oxycodone, CR vs. IR – Nonmedical Use

- Source:  DAWN estimates for the U.S., 2004-2007

- No significant change

- 2006 vs. 2007

**2004**

**2005**

**2006**

**2007**

## Oxycodone, CR vs. IR

- Source:  DAWN estimates for the U.S., 2004-2007

**% of visits**

**Nonmedical use**

**Medical use**

## Nonmedical Use:  Hydrocodone and Oxycodone by Release Type, 2004-2007

- Source:  DAWN estimates for the U.S., 2004-2006

## Nonmedical Use:  All Opiates/Opioids, ED Visit Rates, 2007

**ED visits per 100K population**

- Age

- Source:  DAWN estimates for the U.S., 2007

## Nonmedical Use:  All Hydrocodone, ED Visit Rates, 2007

**ED visits per 100K population**

- Age

- Source:  DAWN estimates for the U.S., 2007

## Nonmedical Use:  All Oxycodone, ED Visit Rates, 2007

**ED visits per 100K population**

- Age

- Source:  DAWN estimates for the U.S., 2007

## Nonmedical Use:  Oxycodone CR,ED Visit Rates, 2007

**ED visits per 100K population**

- Age

- Source:  DAWN estimates for the U.S., 2007

## Nonmedical Use:  Oxycodone IR,ED Visit Rates, 2007

**ED visits per 100K population**

- Age

- Source:  DAWN estimates for the U.S., 2007

## Nonmedical Use:  Oxycodone UK,ED Visit Rates, 2007

**ED visits per 100K population**

- Age

- Source:  DAWN estimates for the U.S., 2007

## Nonmedical Use:  Disposition from ED,Oxycodone by Release Type, 2007

- Nonmedical Use:  Disposition from ED,Oxycodone by Release Type, 2007

- Source:  DAWN estimates for the U.S., 2007

**% of ED visits**

**Controlled**

**Unknown**

**Immediate**

**Some **
**follow-up**

**No evidence**
**of follow-up**
**care**

## Nonmedical Use:  Number of Drugs,Oxycodone by Release Type, 2007

- Nonmedical Use:  Number of Drugs,Oxycodone by Release Type, 2007

- Source:  DAWN estimates for the U.S., 2007

**% of ED visits**

**Controlled**

**Unknown**

**Immediate**

**Multiple**
**drugs**

## Nonmedical Use ED Visits:  Conclusions

- Opioid analgesics nearing 287,000 visits
- 1⁄4 Oxycodone  1⁄4 Hydrocodone
-  in immediate and unknown release types
- Highest visit rates in patients aged 21-54
- Majority of patients treated and released
- Polydrug use was higher for immediate versus controlled release

- Morphine
- Controlled and Immediate Release

## Nonmedical Use of Pharmaceuticals, Selected Opiates/Opioids, 2007

- Source:  National estimates from DAWN, 2007

- * Single- & multi-ingredient formulations

**Notes:**
Starting with illicit drugs:

Here the confidence intervals help you see when differences are not statistically significant.
If the confidence intervals overlap, the estimates may not be different, such as cocaine & marijuana.
CIs also help you visualize the impact of sampling error.  Some estimates are not very precise.

Cocaine:  67,429 – 184,413

Heroin:  31,369 – 63,839

Marijuana:  39,067 – 120,259

Stimulants:  20,860 – 64,216

Amphetamines – about 3⁄4 from toxicology findings
Methamphetamine
When drug screen tests only for amphetamines as a class, amphetamine positive could mean amphetamine or methamphetamine.

## Classification of Morphine Reports

- Controlled release (CR)
- MS Contin (71%)
- Alternate terms:
- Avinza
- Kadian
- Morphine Sulfate SR
- Oramorph SR
- Morphine Extended Release
- Morphine Patches

- Immediate release (IR)
- Morphine Sulfate
- Morphine Pill
- Morphine IR
- Morphine Rapi-Ject
- Roxanol
- Morphelan

## Nonmedical Use of Pharmaceuticals, Morphine, by Release Type, 2004-2007

- Source:  National estimates from DAWN, 2004-2007

**Controlled**

**Immediate**

**Notes:**
Starting with illicit drugs:

Here the confidence intervals help you see when differences are not statistically significant.
If the confidence intervals overlap, the estimates may not be different, such as cocaine & marijuana.
CIs also help you visualize the impact of sampling error.  Some estimates are not very precise.

Cocaine:  67,429 – 184,413

Heroin:  31,369 – 63,839

Marijuana:  39,067 – 120,259

Stimulants:  20,860 – 64,216

Amphetamines – about 3⁄4 from toxicology findings
Methamphetamine
When drug screen tests only for amphetamines as a class, amphetamine positive could mean amphetamine or methamphetamine.

## Morphine, CR vs. IR – All Visits

- Source:  DAWN estimates for the U.S., 2004-2007

- 2006 vs. 2007

- No significant change

**2004**

**2005**

**2006**

**2007**

## Morphine, CR vs. IR – Medical Use

- Source:  DAWN estimates for the U.S., 2004-2007

- 2006 vs. 2007

- No Significant change

## Morphine, CR vs. IR – Nonmedical Use

- Source:  DAWN estimates for the U.S., 2004-2007

- No significant change

- 2006 vs. 2007

## Morphine, CR vs. IR

- Source:  DAWN estimates for the U.S., 2004-2007

**% of visits**

**Nonmedical use**

**Medical use**

## Nonmedical Use:  Hydrocodone and Morphine by Release Type, 2004-2007

- Source:  DAWN estimates for the U.S., 2004-2006

## Nonmedical Use:  All Morphine, ED Visit Rates, 2007

**ED visits per 100K population**

- Age

- Source:  DAWN estimates for the U.S., 2007

## Nonmedical Use:  Morphine CR,ED Visit Rates, 2007

**ED visits per 100K population**

- Age

- Source:  DAWN estimates for the U.S., 2007

## Nonmedical Use:  Morphine IR,ED Visit Rates, 2007

**ED visits per 100K population**

- Age

- Source:  DAWN estimates for the U.S., 2007

## Nonmedical Use:  Disposition from ED,Morphine by Release Type, 2007

- Nonmedical Use:  Disposition from ED,Morphine by Release Type, 2007

- Source:  DAWN estimates for the U.S., 2007

**% of ED visits**

**Controlled**

**Unknown**

**Immediate**

**Some **
**follow-up**

**No evidence**
**of follow-up**
**care**

## Nonmedical Use:  Number of Drugs,Morphine by Release Type, 2007

- Nonmedical Use:  Number of Drugs,Morphine by Release Type, 2007

- Source:  DAWN estimates for the U.S., 2007

**% of ED visits**

**Controlled**

**Unknown**

**Immediate**

**Multiple**
**drugs**

## Nonmedical Use ED Visits:  Conclusions

- Morphine related ED visits nearing 30,000
- Immediate release 
- Controlled release is similar 2004-2007
- Highest visit rates in patients aged 21-54
- Majority of patients treated and released
- Polydrug use is  typical

## Important Considerations:DAWN Depends on ED Medical Records

- Link between ED visit and use of drug
- Dose levels and source of drug unavailable
- Nonspecific drug reports
- Opiates/opioids, unspecified (unnamed)
- Unknown release-type
- Unique names for immediate versus extended release enable better surveillance

## Acknowledgements 

- Rong Cai, Statistician