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Drug Trends: Old Drugs and New Problems - New Drugs and New Problems Jane Maxwell, Ph.D. Center for Social Work Research The University of Texas at Austin The author has no financial disclosure 2 3 Jane Maxwell, UT Addiction Research

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Jane Maxwell, UT Addiction Research Institute, 512 232-0610

Drug Trends: Old Drugs and New Problems - New Drugs and New Problems

Jane Maxwell, Ph.D. Center for Social Work Research The University of Texas at Austin

The author has no financial disclosure

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Jane Maxwell, UT Addiction Research Institute, 512 232-0610

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Average Purity of Heroin Samples in the US: 2003-2011

0% 10% 20% 30% 40% 50% Southeast Asian Southwest Asian Mexican South American 2003 2004 2005 2006 2007 2008 2009 2010 2011

DEA’s Heroin Domestic Monitor Program

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Jane Maxwell, UT Addiction Research Institute, 512 232-0610

Mexican Black Tar Heroin Mexican Brown Heroin South American Heroin

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Heroin

  • Almost all heroin in the U.S. is from Mexico or

South America.

  • East of the Mississippi, white South American

heroin and in the West , Mexican heroin, but seeing Black Tar move eastward and into the South, while South American now seen in Chicago and St Louis.

  • Number of U.S. heroin treatment admissions under

age 25 increased from 16,357 in 1992 to 57,060 in 2010.

  • Increasing heroin use among suburban youth and

young users.

  • Reports of fentanyl mixed with white South

American heroin in the NE and Canada.

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Texas Heroin and Other Opiate Admissions by Age Group: 2005-2012

Heroin

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 50+ 40s 30s 20s U20

Other Opiates

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 50+ 40s 30s 20s U20 Source: DSHS 9

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Jane Maxwell, UT Addiction Research Institute, 512 232-0610

Average Age of Persons Dying with

Mention of Heroin in Texas: 1992-2012

37 39 38 38 38 40 37 38 38 39 39 39 39 40 39 37 40 36 35 34 36

31 32 33 34 35 36 37 38 39 40 41

Age (Years)

Source: DSHS 10

Price of an Ounce of Mexican Black Tar Heroin in Texas: 1987-2012

1000 2000 3000 4000 5000 6000 7000 8000 9000 1987 1989 1991 1h93 1h94 1h95 1h96 1h97 1h98 1h99 1h00 1h01 1h02 1h03 1h04 1h05 1h06 1h07 1h08 1h09 2h11

Source: DEA

11 08/15/2012

Intelligence Division - Indications and Warning Section

All Heroin Purchases Domestic STRIDE Data January 2007 – June 2012

Jan- Mar0 7 Apr- Jun0 7 Jul- Sep0 7 Oct- Dec0 7 Jan- Mar0 8 Apr- Jun0 8 Jul- Sep0 8 Oct- Dec0 8 Jan- Mar0 9 Apr- Jun0 9 Jul- Sep0 9 Oct- Dec0 9 Jan- Mar1 Apr - Jun 10 Jul- Sep1 Oct- Dec1 Jan- Mar1 1 Apr- Jun1 1 Jul- Sep1 1 Oct- Dec1 1 Jan- Mar1 2 Apr- Jun1 2 PPG_mean $695.7 $644.0 $646.7 $564.3 $875.8 $803.3 $873.9 $724.4 $827.9 $741.0 $857.0 $1,096 $1,404 $1,161 $1,147 $812.5 $921.7 $875.6 $774.4 $897.9 $817.1 877.85 Purity_mean 32.41 34.21 37.69 40.50 40.53 35.66 38.38 36.45 33.69 32.47 32.55 27.36 24.07 24.51 24.70 25.84 26.17 28.52 34.17 30.35 30.61 36.79 $695.76 $644.00$646.77 $564.36 $875.89 $803.31 $873.98 $724.43 $827.95 $741.01 $857.00 $1,096.10 $1,161.32 $1,147.37 $812.52 $921.71 $875.67 $774.49 $897.91 $817.11 $877.84 32.4 34.2 37.7 40.5 40.5 35.7 38.4 36.5 33.7 32.5 32.6 27.4 24.1 24.5 24.7 25.8 26.2 28.5 34.2 30.4 30.6 36.8 0.00 20.00 40.00 60.00 80.00 100.00 $0 $200 $400 $600 $800 $1,000 $1,200 $1,400

Purity in Percent Price Per Pure Gram

From October 2007 through June 2012, the price per pure gram of Heroin increased 56%, from $564.36 to $877.85 while the purity decreased 9%, from 41% to 37%.

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Jane Maxwell, UT Addiction Research Institute, 512 232-0610

Other Opiates

  • Shifting back and forth between Rx opiates and
  • heroin. Which came first? Injection drug users report

prescription opiate use predates heroin use and tolerance motivates them to try heroin. But also reports of those who became addicted to prescription

  • piates and when controls were tightened, then

shifted to heroin.

  • Cost difference? In Texas, heroin cap is $10-$20 vs.

$1/mg for 72 mg OxyContin.

  • Pollini et. Al., Problematic use of prescription-type opioids prior to heroin use among young heroin
  • injectors. Substance Abuse and Rehabilitation 2011: 2 173-180, Lankenau SE, et al. (2012).

Initiation into prescription opioid misuse amongst young injection drug users. Int J Drug Policy. 2012 Jan;23(1):37-44. Epub 2011 Jun 20. 13

Nonmedical Use of Pain Relievers: NSDUH 2011

13 14 12 6 3 4 3 2 1 1 2 1 1 1 2 4 6 8 10 12 14 16 All Ages 50-54 55-59 60-64 65 or Older Percent Lifetime Past Year Past Month Baby Boomers—1946-1964

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Cocaine Indicators in Texas: 1998-2012

1 10 100 1000 10000 # PCC Calls % Treatment % Tox Items # Deaths

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

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Jane Maxwell, UT Addiction Research Institute, 512 232-0610

Cocaine: Why the Decline?

  • Poison control, treatment, deaths, & tox lab

indicators down in Texas; price up.

  • Amount of coca under cultivation in South America is

down 15%

  • Demand in Europe for cocaine.
  • Use of Levamisole as a filler with serious medical

consequences.

  • Users in Austin report it is so weak “not worth paying

for” and mixing coke with synthetic cathinones to increase effect.

  • Are the shortages of cocaine and increased supply of

methamphetamine related?

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Jan- Mar07 Apr- Jun07 Jul- Sep07 Oct- Dec07 Jan- Mar08 Apr- Jun08 Jul- Sep08 Oct- Dec08 Jan- Mar09 Apr- Jun09 Jul- Sep09 Oct- Dec09 Jan- Mar10 Apr- Jun 10 Jul- Sept1 Oct- Dec10 Jan- Mar11 Apr- Jun11 Jul- Sept1 1 Oct- Dec11 Jan- Mar12 Apr- Jun12 PPG $97.64 $117.6 $128.1 $114.8 $122.7 $123.9 $181.0 $197.0 $172.6 $173.9 $174.4 $191.9 $191.3 $194.4 $174.7 $173.8 $185.5 $175.8 $164.8 $166.2 $168.9 $175.1 Potency 67.13 59.17 56.84 60.89 57.29 57.19 46.16 44.47 47.90 48.28 45.45 45.59 44.56 44.82 45.91 48.34 48.43 49.12 48.48 49.94 49.59 48.11 $97.64 $117.63 $128.10 $114.87 $122.72 $123.91 $181.04 $197.02 $172.66 $173.97 $174.49 $191.95 $191.35 $194.45 $174.71 $173.87 $185.57 $175.87 $164.86 $166.24 $168.90 $175.16 67.1 59.2 56.8 60.9 57.3 57.2 46.2 44.5 47.9 48.3 45.4 45.6 44.6 44.8 45.9 48.3 48.4 49.1 48.5 49.9 49.6 48.1 0.00 20.00 40.00 60.00 80.00 100.00 $0 $50 $100 $150 $200 $250

Purity in Percent Price Per Pure Gram 8/15/2012

Intelligence Division - Indications and Warning Section

All Cocaine Purchases Domestic STRIDE Data January 2007 – June 2012

From January 2007 through June 2012, the price per pure gram of Cocaine increased 79.%, from $97.64 to $175.16 while the purity decreased 28.3%, from 67.1% to 48.1%.

Price of a Kilogram of Cocaine in Texas: 1987-2013

5000 10000 15000 20000 25000 30000 35000 40000 45000 50000

Source: DEA

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Jane Maxwell, UT Addiction Research Institute, 512 232-0610

Main Global Cocaine Flows: 1998 and 2008

UNODC, World Drug Report , Drug Trafficking, 1998 & 2010 2008

165 124

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New Problems with Cocaine

  • Levamisole is cancer

medication also used in de-worming animals.

  • Can result in

agranulocytosis (discoloration of skin, beginning in ears— sign of skin cell death)

  • Results in neutropenia

(bone marrow does not make enough white blood cells)

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Marijuana

  • Supply changes—Mexican down due to

drought & what is coming across is poor

  • quality. Beginning of increased supply
  • f more hydroponic & indoor grows in

Texas and less from Mexico?

  • Role of Blunts, Wrappers, Dabs, Vapor

Pens in increasing use

  • Increased proportion of treatment

admissions (23%) and more impaired.

  • What will happen with medical

marijuana and legalization?

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Jane Maxwell, UT Addiction Research Institute, 512 232-0610

Monitoring the Future Survey: 1991- 2012: Marijuana Use by 12th Graders

10 20 30 40 50 60 70 80 90 100

1991 1994 1997 2000 2003 2006 2009 2012 % Used in Past Year % Great Risk in Using % Strongly Disapprove of Use % Easy or Very Easy to Get

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Dabs, BHO, Honey, Budder

  • Dabs, shatter wax and vaporizer pens contain hash oil

(“wax”). Supposedly 80%-90% THC. Different methods on the web.

  • Butane Honey Oil or Butane Hash Oil is a golden resin

created by placing dried and ground marijuana into a special pvc filter. Butane gas is shot in through one end of the filter while the other end is placed in a bowl full of water. The filter spews out the fresh oil in to the cold water where it sinks to the bottom. The bottom is scraped and the oil is ready to use.

  • Touch the heated knife point or the pin to the Budder on the

end of a pin and inhale fumes (“and sit down”).

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Jane Maxwell, UT Addiction Research Institute, 512 232-0610

Vapor Pens

  • Advertised for “patients”
  • Cost $100-$200
  • Potency varies
  • Higher percentage of THC
  • No odor. Similar to electric cigarettes
  • Pen-style vaporizers contain 100-150 hits
  • Some can be recharged & refilled
  • http://potappetit.com/the-pen-is-mightier-than-

the-bong-or-mini-vaporizers-got-the-right-stuff/

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Medical Marijuana and Drugged Driving in California: 2007 v. 2010

  • Using 2007 Roadside Survey methodology, marijuana use

by drivers increased from 4.0% testing positive for THC in 2007 to 7.8% in 2010.

  • Nearly 1 in 10 weekend nighttime drivers tested positive

for THC, and in some jurisdictions, the rate was nearly 1- in-5.

  • 39% of holders of medical marijuana permits tested

positive for THC versus 8% without permits.

  • Drivers testing positive for THC did not think it affected

their driving.

Johnson MB et al., 2012. The prevalence of cannabis-involved driving in California. Drug and Alcohol Dependence, 1123, 105-109.

SPICE

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Cannabinoids Identified in U. S. NFLIS Toxicology Labs

JWH-018 64% JWH-073 , 303, 9% JWH-081 , 182 JWH-250 , 461, 14%

19 variations reported in 2010

AM-2201 35% JWH-018 16% JWH-081 6% JWH-122 13% JWH-210 9% SYNTHETIC CANNABINOI D 7%

44 variations reported in 2011

AM-2201 41% 6% SYNTHETIC CANNABINO ID MAM-2201 4% UR-144 13% XLR-11 14%

55 variations reported in 2012

SOURCE: National Forensic Laboratory Information System, 2010, 2011, 2012

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Cannabis vs. Cannabinoids: Clinical Cases

Most symptoms are similar to cannabis intoxication

  • Tachycardia
  • Reddened eyes
  • Anxiousness
  • Mild sedation
  • Hallucinations, acute psychosis
  • Memory deficits

Symptoms not typically seen after cannabis intoxication

  • Seizures
  • Hypokalemia (low potassium)
  • Hypertension (high blood pressure)
  • Nausea/vomiting
  • Coma
  • Agitation, violent behavior

Early articles on psychosis or schizophrenia with synthetic cannabis or cannabis

  • Association between age at onset of psychosis and age at onset of cannabis use in non-affective

psychosis, Galvez-Buccollini, Schizophrenia Research 139 (2012) 157-160.

  • Letter to the Editors, Schizophrenia Research 118 (2010) 309-310.
  • Synthetic cannabinoid JWH-018 and psychosis: An explorative study. Every-Palmer, Drug and

Alcohol Dependence 117 (2011) 152-157.

  • Spicing things up. Spaderna et al., Psychopharmacology (2013) 228:525-540
  • Miotto et al., Clinical & pharmacological aspects of bath salt use. Drug & Alcohol Dependence

(2013) in press. 29

  • U. S. Human Exposure Calls for Synthetic

Cannabinoids and Cathinones and Impact of Federal Regulations

100 200 300 400 500 600 700 800

Jan 2010 Jul Jan 2011 Jul Jan 2012 July Jan 2013

The Effect of Federal Controls on Synthetic Cannabis Calls to Poison Centers 100 200 300 400 500 600 700 800

Jan 2010 Jul Jan 2011 Jul Jan 2012 July Jan 2013

The Effect of Federal Controls on Synthetic Cathinone Calls to Poison Centers 30

SOURCE: American Association of Poison Centers

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Who are the users of psychoactive drugs (synthetics, hallucinogens, phenethylamines, tryptamines, MDMA, etc.)?

  • Users of synthetic cannabis: Preliminary analysis
  • f poison center, emergency room, and treatment

data show young (under age 20) males with low levels of employment and education and high levels of legal problems.

  • Users of synthetic cathinones and hallucinogens

more likely to be slightly older (26-30 years).

  • Users of synthetic cathinones, tryptamines, LSD,

and phenethylamines more likely to have more serious consequences when seen in emergency rooms, etc.

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Amphetamine-Type Stimulants: MDMA, 2C-xx, Khat, Meth, Amphet, Synthetic Cathinones

An Emerging Liking for Speedy or Upper Drugs and Examples of Drug Replacement

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Possible reason for the changes we are seeing?

1. MDMA drought 2. Change in supply of methamphetamine as precursors shift from pseudoephedrine, which is now limited to small number of tablets in US and banned in Mexico, to P2P/Phenylacetone, which is banned in US but available in Mexico. 3. The search for MDMA replacements using other Amphetamine Type Substances (ATS)?

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Jane Maxwell, UT Addiction Research Institute, 512 232-0610

Glimpses of MDMA Situation in U.S.: 1999-2013

10 20 30 40 50 60 70 80 90

2001 2003 2005 2007 2009 2011 2013

Results of Pill Tests Containing MDMA*

Any MDMA MDMA Only 5000 10000 15000 20000 25000 30000

2006 2009 2012

MDMA Reports: NFLIS Forensic Labs 2006- 2012

*http://www.ecstasydata.org/stats_su bstance_by_year.php

Source: DEA NFLIS 34

What’s “Molly”?

  • Ecstasy pills with little MDMA and lots of caffeine,

meth, assorted drugs? - or -

  • A pure crystalline form of MDMA, most often sold

as a powder filled capsule? - or -

  • Methylone? (Bath salts)? Reports of desired

effects of euphoria, but also increased paranoia, agitated delirium, hallucinations, psychotic episodes, violent or destructive self-harm, including death

  • Bottom line - Molly is no longer just a pure form
  • f MDMA ecstasy, but may be a drug that is even

more harmful than ecstasy itself.

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From the term “Bath Salts” to…

2C Phenethylamine Psychedelics related to datura, mescaline, 25I- NBOMe (micrograms, not milligrams) Some were created in the past to imitate MDMA. Synthetic Cathinones Mephedrone, methylone, 4- MEC Stimulants related to methcathinone, MDMA, amphetamines Tryptamines 5-MeO-DMT & 4-AcO-DMT Psychedelics related to psilocin & bufotenin Piperazines BZP & TFMPP Stimulants And Dissociatives related to ketamine and PCP and Opioids related to morphine, fentanyl, and heroin.

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Synthetic Cathinones Identified in US NFLIS Toxicology Labs

SOURCE: National Forensic Laboratory Information System, 2010, 2011, 2012 .

17 varieties identified in 2010 n=731 25 varieties identified in 2011 n=6,949 37 varieties identified in 2012 n=14,239

4MMC 33% MDPV 52% METHY LONE 11% 4-MEC 4% 4-MMC 5% MDPV 53% METHYLONE 26% ALPHA-PBP 18% PENTEDRONE 5% 4-MMC 20% MDPV 21% METHYLONE 23% 37

Clinical effects of synthetic cathinones in patients admitted to ED (N=236)

Agitation 8 2 % Com bative/ Violent behavior 5 7 % Tachycardia/ Racing heart 5 6 % Hallucinations 4 0 % Paranoia 3 6 % Confusion 3 4 % Myoclonus/ Movem ent disorders 1 9 % Hypertension 1 7 % Chest pain 1 7 % CPK elevations 9 %

Source: Spiller et al., 2011

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New and Old Hallucinogens in the U.S.: NFLIS 2010-5/2013

20 40 60 TFMPP 2C-x MDMA 5MEO DMT Hallucinogen LSD Psilocin Psilocybine/Psilocin Psilocybine Other % of All Hallucinogens Tested 2013 2012 2011 2010

SOURCE: DEA NFLIS 39

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Jane Maxwell, UT Addiction Research Institute, 512 232-0610

08/15/2012 Intelligence Division - Indications and Warning Section

All Methamphetamine Purchases Domestic STRIDE Data January 2007 – June 2012

Jan- Mar07 Apr- Jun07 Jul- Sep07 Oct- Dec07 Jan- Mar08 Apr- Jun08 Jul- Sep08 Oct- Dec08 Jan- Mar09 Apr- Jun09 Jul- Sep09 Oct- Dec09 Jan- Mar10 Apr- Jun10 Jul- Sep10 Oct- Dec10 Jan- Mar11 Apr- Jun11 Jul- Sep11 Oct- Dec11 Jan- Mar12 Apr- Jun12 PPG_mean $158.9 $226.6 $288.6 $306.4 $244.7 $244.3 $199.4 $179.4 $188.7 $138.7 $140.2 $127.6 $126.3 $111.7 $104.3 $98.29 $104.6 $93.14 $93.71 $86.20 $90.39 81.28 Purity_mean 59.39 44.94 40.67 42.46 48.07 54.86 55.80 65.17 67.20 72.15 73.63 76.90 82.28 87.86 88.22 90.08 89.62 92.04 89.79 91.08 91.91 92.89 $158.96 $226.66 $288.69 $306.49 $244.79 $244.31 $199.47 $179.41 $188.78 $138.76 $140.22 $127.65 $126.30 $111.77 $104.34 $98.29$104.66 $93.14 $93.71 $85.24 $90.39 $81.28 59.4 44.9 40.7 42.5 48.1 54.9 55.8 65.2 67.2 72.2 73.6 76.9 82.3 87.9 88.2 90.1 89.6 92.0 89.8 91.1 91.9 92.9 0.00 20.00 40.00 60.00 80.00 100.00 $0 $50 $100 $150 $200 $250 $300 $350

Purity in Percent Price Per Pure Gram

From July 2007 through June 2012, the price per pure gram of methamphetamine decreased 72%, from $288.69 to $81.29, while the purity increased 128%, from 41% to 93%. Intelligence Division - Indications and Warning Section

Methamphetamine & Amphetamine Indicators in Texas: 1997-2012

1 10 100 1000

# PCC Calls % Tmt Admits # Deaths % of Tox Items

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

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Different Manufacturing Processes

  • I. Ephedrine/Pseudoephedrine Based (d-form): (1% of samples
  • ver 6g tested)
  • A. “Nazi Method”-lithium, anhydrous ammonia
  • B. Cold method-red phosphorus, iodine crystals
  • C. “One Pot” and “Shake and Bake” cooking using dry

ammonia nitrite and cough syrup rather than liquid anhydrous ammonia. Still used in rural areas and Midwest and South, but usually produces less than 6 g

  • f methamphetamine.
  • II. P2P/Phenylacetone (Illegal in US-Schedule II, precursors

legal in Mexico) (l and d,l-forms): (95% of samples over 6g tested). If drug is 100% potent, it’s all d-form. If 0% potent, is all l-form. Mexican chemists are refining their process to produce more potent P2P meth.

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Jane Maxwell, UT Addiction Research Institute, 512 232-0610

DEA Methamphetamine Profiling Program: 2010-2nd Q 2013

0% 20% 40% 60% 80% 100%

Purity and Potency

Purity Potency

0% 20% 40% 60% 80% 100%

Production Routes

P2P Phosphorus Iodine

Source: DEA

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Local Texas Reports on Meth Use

  • Street outreach workers in Austin report more

psychosis with the P2P meth, better highs, and some moving back to smoking Ice since it is available.

  • Other outreach workers reported closed groups
  • f MSM using meth, often injecting, and

increasing cases of syphilis.

  • Conversion labs in Texas change liquid meth

from Mexico to powder or Ice.

  • Increases in meth use also reported by other

CEWG members.

  • Increasing need for treatment as this more potent

meth spreads.

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http://www.uclaisap.org/slides/synthetic-drug-training-package.html

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Jane Maxwell, UT Addiction Research Institute, 512 232-0610

Data Sources

  • Monitoring the Future Surveys: 2011-2012
  • SAMHSA’s Drug Abuse Warning Network: 2011-

2012

  • Texas poison control centers: 1998-6/1/2013
  • Texas treatment data: 1986-2012
  • Mortality from poison control centers: 2010-2012
  • DEA’s National Forensic Laboratory Information

System (NFLIS): 2005-June 2013

  • DEA’s STRIDE system
  • Reports from NIDA’s Community Epidemiology

Work Group members June 2013

Jane C. Maxwell, Ph.D. Senior Research Scientist Addiction Research Institute Center for Social Work Research The University of Texas at Austin 1717 West 6th, Suite 335 Austin, Texas 78703 512 232-0610 http://www.utexas.edu/research/cswr/gcattc/

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