OSAM Surveillance of Drug Abuse Trends in the Cleveland Region Ohio Substance Abuse Monitoring Network Drug Abuse Trends in the Cleveland Region LAKE Regional Epidemiologist: GEAUGA Angela Arnold, MS CUYAHOGA LORAIN MEDINA ASHLAND WAYNE HOLMES OSAM Staff: R. Thomas Sherba, PhD, MPH, LPCC OSAM Principal Investigator Beth E. Gersper, MPA OSAM Coordinator Nicholas J. Martt, MSW, LSW OSAM Research Administrator Page 78 Data Sources for the Cleveland Region This regional report was based upon qualitative data collected via focus group interviews. Participants were active and recovering drug users recruited from alcohol and other drug treatment programs in Cuyahoga and Lake counties. Data triangulation was achieved through comparison of participant data to qualitative data collected from regional community professionals (treatment providers and law enforcement) via focus group interviews in Cuyahoga and Lake counties, as well as to data surveyed from American Court and Drug Testing Services, which processes drug screens in Medina (Medina County) from across the region and the Bureau of Criminal Investigation (BCI) Richfield office, which serves the Cleveland, Akron and Youngstown areas. All secondary data are summary data of cases processed from June 2013 through January 2014. In addition to these data sources, Ohio media outlets were queried for information regarding regional drug abuse for January through June 2014. Note: OSAM participants were asked to report on drug use/knowledge pertaining to the past six months prior to the interview; thus, current secondary data correspond to the current reporting period of participants. OSAM Drug Trend Report January-June 2014 Surveillance of Drug Abuse Trends in the Cleveland Region Regional Profile Indicator1 Ohio Cleveland Region OSAM Drug Consumers Total Population, 2010 11,536,504 2,287,265 39 Gender (female), 2010 51.2% 51.8% 44.7%2 Whites, 2010 81.1% 74.0% 86.8%3 African Americans, 2010 12.0% 18.0% 10.5%3 Hispanic or Latino Origin, 2010 3.1% 4.4% 2.7%4 High School Graduation Rate, 2010 84.3% 82.8% 84.6% Median Household Income, 2012 $46,873 $52,247 $19,000 to $21,9995 Persons Below Poverty Level, 2012 16.2% 12.4% 15.4%6 1 Ohio and Cleveland region statistics are derived from the most recent US Census, and OSAM drug consumers were participants for this reporting period: January - June 2014. was unable to be determined for 1 participant due to missing and/or invalid data. Race was unable to be determined for 4 participants due to missing and/or invalid data. 4 Hispanic or Latino origin was unable to be determined for 2 participants due to missing and/or invalid data. 5 Participants reported income by selecting a category that best represented their household’s approximate income for 2013. Income status was unable to be determined for 1 participant due to missing and/or invalid data. 6 Poverty status was unable to be determined for 4 participants due to missing and/or invalid data. 2 Gender 3 Cleveland Regional Participant Characteristics Gende r Gender Drug Consumer Characteristics* (N = 39) Male 2121 Female 17 ˃20 3 Age Age 20s 16 30s 9 40s 6 50s 3 ≥60 2 Education Education Less than high school graduate 6 High school graduate 17 Some college or associate's degree 15 Bachelor's degree or higher 1 Household Household Income Income <$11,000 10 $11,000 to $18,999 7 $19,000 to $29,999 4 $30,000 to $38,000 7 >$38,000 10 Alcohol 31 Crack Cocaine 14 Ecstasy 5 Drugs Used** Drugs Used** Heroin 20 LSD 2 Marijuana 19 Methamphetamine 6 Powdered Cocaine 11 Prescription Opioids 17 Prescription Stimulants 8 Sedative-Hypnotics 12 Other Drugs*** 6 0 5 10 *Not all participants filled out forms; therefore, numbers may not equal 39. **Some respondents reported multiple drugs of use during the past six months. ***Other drugs: Bath salts, DMT, ketamine, psilocybin mushrooms, Suboxone® and synthetic marijuana. 2013 OSAM Drug Trend Report January-June 2014 15 20 Number of of Participants Number participants 25 30 35 Page 79 Page 8 Surveillance of Drug Abuse Trends in the Cleveland Region Historical Summary In the previous reporting period (June – December 2013), crack cocaine, ecstasy, heroin, marijuana, PCP (phencyclidine), prescription opioids, prescription stimulants, Suboxone® and synthetic marijuana were highly available in the Cleveland region. Changes in availability included increased availability for heroin and decreased availability for powdered cocaine; likely increased availability for methamphetamine, prescription opioids, sedative-hypnotics and Suboxone®. Participants reported powdered heroin as more available than black tar heroin in the region. Participants mentioned fewer distinctions between brown and white powdered availability due to the great variation of and broad spectrum of heroin colors. Lake County Crime Lab reported processing brown, gray, tan and white powdered heroin as well as compressed rock forms of heroin. Participants reported black tar availability as moderate, with higher availability of that type of heroin for the west side of Cleveland. Participants suggested several reasons for increased heroin availability. First, participants reported dealers switching from other drug sales to more profitable heroin sales. Second, the heroin market was extremely resilient even following large law enforcement drug busts. Finally, the decrease in available prescription opioids due to the increased oversight in prescribing patterns in addition to abuse deterrent changes in pill formularies purportedly increased the demand for heroin. Community professionals also reported increased heroin availability as seen in the increased number of addicted clients and increased number of heroin related law enforcement cases. Participants and community professionals discussed current quality of heroin in relation to cuts (adulterates) in the drug (i.e. fentanyl) which led to many overdoses. Participants described heroin users as under 30 years of age and typically prescription opioid abusers. Generally, participants agreed that younger blacks were not the typical heroin user, but whites and Hispanics used heroin more often. Treatment providers also reported an increase in younger individuals using heroin. Participants did not agree on change in availability of prescription opioids, but community professionals reported increased availability for these drugs. Treatment providers suggested doctors did not monitor prescription opioids Page 80 closely enough and explained that illicit use was fueled primarily through diversion; law enforcement noted an influx of pills from outside Ohio. Community professionals also reported increased availability of Suboxone®. Law enforcement observed that Suboxone® use mirrored the increased use of heroin and explained that it was due to addicts attempting to combat withdrawal when heroin was unavailable. Participants did not express difficulty in finding the drug through friends or dealers, but a few participants reported challenges involved with a managed treatment program. The BCI Richfield Crime Lab reported an increase in the number of Suboxone® and Subutex® cases it processed during the reporting period. Demand for Xanax® appeared to be increasing as heroin users sought this particular sedative-hypnotic. Law enforcement reported increased availability for Xanax® and participants reported increased popularity of the drug. Typical illicit users of Xanax® were often described as younger and addicted to other drugs, especially heroin. Community professionals reported an increase in methamphetamine availability, while most participants reported little personal experience or knowledge about the drug. Cleveland news sources also reported that methamphetamine labs had increased in number due to the ease with which the drug was made and its portability with the one-pot method. The BCI Richfield Crime Lab reported that the number of methamphetamine cases it processes had increased; the lab reported processing mostly offwhite and gray powdered methamphetamine along with a small amount of crystal methamphetamine. Participants commented on the ever fluctuating availability of methamphetamine and added that availability was lowest in the urban centers and higher in the region’s more rural areas. Participants described typical users of methamphetamine as white and both male and female. Lastly, PCP (phencyclidine) remained highly available in the city of Cleveland. Participants continued to report an area called ‘Water World’ on the northeast side of Cleveland as the origin of the region’s PCP. Reportedly, availability of the drug was only through specific dealers. Participants described typical PCP users as younger, black and more often residing on Cleveland’s east side. OSAM Drug Trend Report January-June 2014 Surveillance of Drug Abuse Trends in the Cleveland Region Current Trends The BCI Richfield Crime Lab reported that the number of powdered cocaine cases it processes has remained the same during the past six months. Corroborating data also indicated the presence of cocaine in the region. American Court and Drug Testing Services reported that 5.9 percent of the 971 individuals screened through its Medina lab during the past six months were positive for cocaine (crack and/or powdered cocaine). In addition, media outlets reported on law enforcement seizures of powdered cocaine in the region this reporting period. A combined effort of Elyria and North Ridgeville police (Lorain County) seized approximately 50 grams of cocaine when they searched a local residence (www.morningjournal.com, Jan. 21, 2014). Participants reported that the availability of powdered cocaine has slightly increased during the past six months. A participant remarked, “I was able to find [powdered cocaine] anytime I wanted it. One or two phone calls. I could always find it easily.” Community professionals did not identify this drug as a top trending drug. A treatment provider felt powdered cocaine had become less available. 2013 OSAM Drug Trend Report January-June 2014 Participants Increase Law enforcement No Comment Participants most often reported the current quality of powdered cocaine as ‘7’ on a scale of ‘0’ (poor quality, “garbage”) to ‘10’ (high quality); the previous most common score was ‘4.’ Participants reported that powdered cocaine in the region is cut (adulterated) with baby laxative, baking soda, caffeine, ether, head shop cuts (often sold as carpet and room deodorizers) as well as numbing agents. Participants indicated varying quality of the drug. A participant reflected, “I spent a lot of money and I wasn’t going to spend it on junk [low quality cocaine].” Another participant said, “With my [young] age and [limited] resources, I could only get very low quality.” Overall, participants reported a decrease in the quality of powdered cocaine during the past six months. Powdered Cocaine Community professionals most often reported the current availability of powdered cocaine as ‘5;’ the previous most common score was ‘8.’ A treatment professional shared, “I think you can find [powdered cocaine] readily. I don’t see clients coming in with powder [cocaine] as a primary drug of choice [however].” Reported Availability Change during the Past 6 Months Treatment providers No Consensus Cutting Agents Reported by Crime Lab l levamisole (livestock dewormer) l lidocaine and procaine (local anesthetics) Current street prices for powdered cocaine were consistent among participants with experience buying the drug. Participants revealed that the price of the drug is dependent on the quality one obtains, as well as higher prices in rural areas or outlying suburbs. A participant explained, “You can spend the extra on gas and drive [into the city] or you can buy local and pay more.” Powdered Cocaine Powdered cocaine is moderately to highly available in the region. Participants most often reported the drug’s current availability as ‘8’ on a scale of ‘0’ (not available, impossible to get) to ‘10’ (highly available, extremely easy to get); the previous most common score was ‘7.’ A participant described powdered cocaine availability and explained, “Yes, one phone call [to obtain powdered cocaine], two at the most. For specific drugs, there’s specific drug dealers. For cocaine would be completely different than the person I’d call for heroin.” Another participant stated, “[Powdered cocaine] … it’s a phone call away … every dealer I went to had crack [cocaine], ‘coke’ (powdered cocaine) or heroin. [Location] doesn’t matter - east side, west side, they’ve got it.” Still another participant commented, “Yes, [powdered cocaine is] available, but I don’t think it’s as accessible as other things. A few phone calls away.” Powdered Cocaine Powdered Cocaine Current Street Prices for Powdered Cocaine a gram $60-80 1/8 ounce (aka “eight ball”) $150-300 Page 81 Page 8 Surveillance of Drug Abuse Trends in the Cleveland Region Participants and community professionals described typical powdered cocaine users as of higher socio-economic status, more often white, older individuals (40-50 years of age with few mentions of users under the age of 25), those who work in physically demanding occupations and crack users. Participants commented: “The powder [cocaine] users are well-employed executives, teachers, people with good jobs who can keep up with their lives and pay their bills; Landscapers and construction people go in the truck for a quick couple of lines [of powdered cocaine]; People in bars [use powdered cocaine] a lot. Barmaids, men in bars who offer it to women in bars.” Crack Cocaine Crack cocaine remains highly available in the region. Participants most often reported the drug’s current availability as ‘10’ on a scale of ‘0’ (not available, impossible to get) to ‘10’ (highly available, extremely easy to get); the previous most common score was also ‘10.’ Participants reported that crack cocaine is very easy to obtain. A participant commented, “[Crack cocaine is] everywhere. You don’t even have to look for it, it finds you. I could be walking down the street and people would ask me if I messed with that ‘hard’ (crack cocaine) … [but] when there is a bust in the neighborhood, [crack cocaine is] less likely to be on the street - It’s a phone call [to a dealer to obtain].” Participants reported white and yellow (“butter”) as the most available types of crack cocaine in the Cleveland area. A participant commented, “I know that every time I went to get my drug of choice (heroin), [crack cocaine] was always available. It was white, like yellowish color. Easily available.” Community professionals most often reported current availability of crack cocaine as ‘7;’ the previous most common score was ‘10.’ A treatment provider reflected, “Even heroin addicts are smoking crack.” A law enforcement officer commented, “[Crack cocaine is] still out there … people still smoke crack.” Page 82 Media outlets reported on law enforcement seizures of crack cocaine in the region this reporting period. A Cleveland man was arrested by police when he was caught advertising crack cocaine and marijuana on Craigslist (www. impact.cleveland.com, Jan. 13, 2014). A man in Ashland County pleaded guilty to four counts of trafficking crack cocaine and received a four-year prison sentence (www. herald-dispatch.com, Jan. 16, 2014). An ongoing investigation led Shaker Heights (Cuyahoga County) detectives to a crack cocaine dealer in their city (www.cleveland.com, May 6, 2014). A woman let her grandmother borrow her car and reported it missing five hours later; her grandmother has a history of taking cars from family members to smoke crack cocaine on the east side of Cleveland (www.cleveland.com, May 12, 2014). A majority of participants reported that the availability of crack cocaine has remained the same during the past six months. Community professionals also suggested that availability has remained the same during the past six months. However, a few treatment providers reported a decrease in crack cocaine availability as one commented, “The young ‘corner boys’ (drug dealers) have switched to heroin. I very seldom have a client who comes in who’s struggling with crack as a primary drug.” A law enforcement officer said, “The heroin dealers that we’re getting, the majority used to be crack dealers. I think their inexperience and poor connections contributes a lot to the [heroin] overdoses.” The BCI Richfield Crime Lab reported that the number of crack cocaine cases it processes has remained the same during the past six months. Crack Cocaine Participants reported that the most common route of administration for powdered cocaine remains snorting. Participants estimated that out of 10 powdered cocaine users, five would snort, three would smoke and two would intravenously inject (“shoot”) the drug. Participants explained that users will often cook their powdered cocaine into crack cocaine and smoke it. A participant explained, “We like crack better so we get [powdered cocaine] and crack it up. It’s easier to find and cheaper that way.” Reported Availability Change during the Past 6 Months Participants No Change Law enforcement No Change Treatment providers No Change Participants most often rated the current quality of crack cocaine as ‘9’ on a scale of ‘0’ (poor quality, “garbage”) to ‘10’ (high quality); the previous most common score was ‘5.’ Participants reported that crack cocaine in the region is cut with amphetamines (“speed”), baby formula, baby laxative, baking soda, benzodiazepines, caffeine, head shop cuts, heroin, methamphetamine and numbing agents. A OSAM Drug Trend Report January-June 2014 Surveillance of Drug Abuse Trends in the Cleveland Region Crack Cocaine participant remarked, “[Crack cocaine] doesn’t burn right if it has pills or stuff in it.” A slight majority of participants reported no change in the quality of crack cocaine during the last six months, while other participants felt quality had decreased. A participant talked about fluctuating quality of crack and shared, “When [crack cocaine] was more pure, a hit would last for 45 minutes, now it’s only 20 minutes.” Other participants discussed how quality can be increased by cooking the drug again. A participant commented, “I would have to cook [crack cocaine] back to make it more potent.” Cutting Agents Reported by Crime Lab l levamisole (livestock dewormer) l lidocaine and procaine (local anesthetics) Crack Cocaine Current street prices for crack cocaine were consistent among participants with experience buying the drug. A participant said, “Dealers like to sell ‘20s’ ($20-pieces of crack cocaine) and ‘50s’ ($50 pieces) - not larger amounts because they make more money on those [smaller] sizes.” Current Street Prices for Crack Cocaine 1/10-3/10 gram pieces $20 1/2 gram (aka “fifties” or “block”) $50 1/8 ounce (aka “eight ball”) $150-200 The most common route of administration for crack cocaine remains smoking. Out of 10 crack cocaine users, participants reported that approximately eight would smoke and two would intravenously inject (“shoot”) the drug. A participant stated, “A lot more people smoke crack now because you get higher than you do from powder. There’s a lot more crack smokers now.” A description of a typical crack cocaine user did not emerge from the data. Participants described crack cocaine users as whites, blacks, Hispanics, east-siders and west-siders. A participant said, “[Crack cocaine has] got an unexpected crowd. It’s very under the table. I’ve seen the homeless stereotype people, but I’ve also seen rich suburban people smoke it. There’s a lot of diversity there.” Another 2013 OSAM Drug Trend Report January-June 2014 participant said, “It’s getting more suburban, people in the outlying areas. It’s not just an urban person.” Community professionals also had trouble identifying typical crack cocaine users. Treatment providers suggested users are from many demographic groups, especially middle-aged users. Treatment providers commented: “I’ve seen a lot more women in their 40s smoking crack than I’ve seen younger people. That’s a trend. Also it’s both white and black; I see 40 [years of age] and over, African-American women; It’s 45 [years] on up.” Heroin Heroin remains highly available in the region. Participants and community professionals most often reported the overall current availability of heroin as ‘10’ on a scale of ‘0’ (not available, impossible to get) to ‘10’ (highly available, extremely easy to get); the previous most common scores from both respondent groups were also ‘10.’ Participants discussed heroin availability and resiliency of the supply. A participant remarked, “Heroin is at a ‘9’ or a ‘10’ for availability. Every time the police bust, they rip down 120 guys at one time, but those neighborhoods have so many youth ready to take up the phone from the guy ….” Other participants shared: “[Heroin] was [easy to get] like crack; [Heroin] is my drug of choice, so I know it is super easy to get; I always went to Cleveland. You didn’t even have to blink and somebody would be coming up to you; I know dealers who will pass out samples.” Participants noted fewer differences in heroin availability between the west and east sides of the city of Cleveland than previously, as one participant explained, “[Heroin is] everywhere. If you’re from the east side you get it on the east, if you’re from the west side, that’s where you get it.” Community professionals continued to cite heroin as the most available drug in the region. While many types of heroin are currently available in the region, participants and community professionals continued to report powdered heroin as the most available type in the region. A participant commented, “I think it is white and brown powder [heroin that is most available], ‘tar’ (black tar heroin is) a little scarcer.” A treatment counselor said, “Brown heroin is what I hear the most about. I hear that tar is primo, but hard to get. You really have to know people for that.” A law enforcement officer also reported, “Mostly the brown powder is available.” Participants and law enforcement officers most often reported current availability Page 83 Page 8 Surveillance of Drug Abuse Trends in the Cleveland Region Participants mentioned fewer distinctions between brown and white powdered availability due to the great variation of and broad spectrum of heroin colors. Heroin colors reported by participants this reporting period included the typical brown powder, tan, dark brown and chunk; also reported were blue, purple, green, white and gray varieties that resemble drywall, concrete or gravel. A participant said, “I did white powder [or] brown powder, so I can get [heroin] anywhere; I have seen dry-wall gray, light gray. I’ve seen all kinds of shit [colored heroin] - shit that looks like sand.” Another participant shared, “There’s definitely different kinds [of heroin]. I’ve seen blue, purple, cream, milky stuff that’s tannish.” Corroborating data also indicated the presence of heroin in the region. American Court and Drug Testing Services reported that 13.2 percent of the 971 individuals screened through its Medina lab during the past six months were positive for opiates. Media outlets reported on law enforcement seizures of heroin in the region this reporting period. The U.S. attorney’s office in Northeast Ohio indicted 20 individuals as it begins to prosecute those who are responsible for drug overdose deaths (www.wkyc.com, Jan. 14, 2014). A 10-year-old boy let Lorain (Lorain County) police officers into his home to save his dad who was overdosing on heroin; officers administered Narcan® (naloxone) to save the man (www.morningjournal.com, Jan. 16, 2014). Cuyahoga County prosecutors arrested two individuals believed to have caused eight heroin overdoses (at least three deaths included in that total) by selling heroin laced with fentanyl, a very potent prescription opioid (www.vindy.com, March 7, 2014). Lake County law enforcement arrested a man for trafficking and possession of 35 grams of heroin (www. newsnet5.com, March 14, 2014). A Lorain County man was arrested and charged after shooting up heroin in the restroom of a restaurant; he overdosed and was resuscitated with Narcan® (www.newsnet5.com, March 20, 2014). Lake County officials have increased their efforts targeting illegal drug activity in and around hotels and motels; throughout a six week period, 14 suspects were arrested and nearly 40 grams of heroin, 10 grams of cocaine and two ounces of marijuana have been seized (www.cleveland.com, June 5, 2014). Geauga County Job and Family Services reported an increase in number of children in Page 84 their custody due to parents using heroin (www.wkyc. com, April 17, 2014). Participants and community professionals reported that the availability of heroin has increased during the past six months. A participant observed, “[Heroin] can’t get more available. When a 15-year-old kid can figure out how to get it, how hard can it be?” A health professional said, “Based on the increase over the last six months and the amount of patients I’ve seen, I’d definitely say [heroin is] more available. It’s insane.” Law enforcement officer shared, “A girl ‘ODs’ (overdoses) and she doesn’t die, and her friends say, ‘You were really lucky … she says, ‘Yeah, I was lucky.’ And in the next conversation she’s trying to recruit others to use that [same] heroin.” Another officer noted, “The ‘grays’ (gray-colored heroin) I’ve seen from time to time. It’s more available than it’s ever been in the city, there are more hookups, more in different parts of Cuyahoga County than we’ve ever encountered.” The BCI Richfield Crime Lab reported that the number of powdered heroin cases it processes has increased during the past six months while the number of black tar cases has remained the same; the lab reported processing primarily white, brown and gray powdered heroin. Heroin of black tar heroin as ‘2;’ the previous most common score by participants was ‘4.’ A treatment provider commented, “People are not doing the tar anymore, it’s all powder.” Reported Availability Change during the Past 6 Months Participants Increase Law enforcement Increase Treatment providers Increase Participants and community professionals agreed that powerful economic forces are driving the increase in heroin availability. Despite law enforcement activity, participants and community professionals reported a limitless network of heroin and dealers. A participant explained, “Heroin got cheaper and a longer high - cheaper to get for the dealer and more clientele.” An officer explained, “The [heroin] clientele is better than crack [clientele]. The new market seems to be going younger and younger as you have a transition from prescription pills to heroin. It’s more middleclass America getting into this and it’s the best market in the world. They’re reliable and they pay.” Participants most often reported the overall current quality of brown powdered heroin as ‘6,’ white powdered heroin as ‘9’ and black tar heroin as ‘10’ on a scale of ‘0’ OSAM Drug Trend Report January-June 2014 Surveillance of Drug Abuse Trends in the Cleveland Region Heroin Participants reported that heroin in the region is cut with baby laxatives, cocaine, cocoa powder, fentanyl, head shop cuts (typically sold as room and carpet deodorizers), methamphetamine, mannitol, methadone, sleep aids (Dormin®, NoDoz®) and vitamin B-12. A law enforcement officer shared, “[Head shops] sell the cut - the sleeping pills ... and every kind of cut - mannitol, Anestol®, Sleepinal® and anything to color it with.” Cutting Agents Reported by Crime Lab l diphenhydramine (antihistamine) l quinine (antimalarial) Participants and community professionals further discussed fentanyl cut heroin. Participants shared: “The dealer never told me if it had fentanyl in it, but I could always tell. It had a stone look to it; It wasn’t sold as being with fentanyl in it, but you could tell; I don’t know if heroin is getting stronger, but they’re adding fentanyl. I flat lined two times and OD’d four times. You never know what you’re getting.” Other participants shared similar experiences. A treatment provider said, “Fentanyl has become a trend. You hear a lot on the news and in the papers and people are dying of it. [Heroin users] need to be made aware of it. It’s not heroin it’s a synthetic drug and it’s hitting the hotlist.” A law enforcement officer said, “[Heroin with] fentanyl has cropped up a lot lately. Sometimes that’s represented as ‘china white.’ It’s bringing back an old term for a new product.” Participants and community professionals expressed concern about how frequently overdose occurs. Participants reasoned: “All these overdoses you hear about are young kids; Rookie drug dealers too; People see that you can make a lot of money and they just jump in the game and don’t know what they are doing and selling something so pure - not cutting it and they are killing people.” 2013 OSAM Drug Trend Report January-June 2014 Participants reported that heroin is available in different quantities. Reportedly, powdered heroin is most commonly sold by the gram. A participant explained, “I think it is people that just can’t afford [larger quantities] that get ‘points’ (1/10 grams) instead of chunks … ‘bundles’ (approximately one gram).” Participants and law enforcement discussed differences in pricing based on location. Participants explained: “It’s cheaper [west of Cleveland] … It’s higher pricing further east; On the west side, it’s [per] hit pricing. In Cleveland, don’t call the dealer for less than $20-40 orders.” Law enforcement also noted differences between the east side and the west side pricing, as well as pricing differences among demographics: “It was always heard that it’s cheaper on the west side. We say, among ourselves, ‘You got the white boy price,’ meaning it’s higher [price] to the white consumer and that’s who’s buying it.” Heroin (poor quality, “garbage”) to ‘10’ (high quality); the previous most common overall quality score was ‘8.’ A majority of participants felt that the quality of heroin has remained the same during the past six months, albeit variable. A participant explained, “It’s who you know. There’s great [quality heroin] and bad on the east [side], great and bad on the west side.” Participants advised: “This sounds crazy, but you need to build a relationship with your dealer to not get ripped off or get bad [quality heroin]; I would stick with somebody you know. If you just go driving and they see a white girl driving, they’re going to rip you off.” Current Street Prices for Brown Powdered and Black Tar Heroin 1/10 gram) $10-20 1/2 gram) $60-70 A gram $90-120 Participants reported that the most common route of administration for heroin remains intravenous injection (“shooting”). Out of 10 heroin users, participants reported that approximately nine would shoot, one would snort and an occasional user would smoke the drug. Participants continued to report that those who are new to heroin are more likely to snort before progressing to shooting. One participant commented, “There’s a 90 percent chance you’re going to end up shooting. Pretty much all heroin addicts started snorting - every addict I know started [using heroin by] snorting.” The Cleveland region has a needle exchange program operated by The Free Clinic of Greater Cleveland and many users continue to report obtaining needles from there as well as obtaining needles from pharmacies by posing as a diabetic patient or buying them from other users and occasionally dealers. Some participants reported it continues to become more difficult to get clean needles at certain retailers. Other participants discussed purchasing needles from dealers and commented: “Some drug dealers will sell me a needle with the heroin. [The syringe] was free; My drug dealers were always buying needles from me; Some drug dealers will sell them to you for $5 per ‘rig’ (syringe). You can get them from other people - diabetics, horse and Page 85 Page 8 Surveillance of Drug Abuse Trends in the Cleveland Region tractor supply [stores] - I used horse tranquilizer needles.” An officer described the frustration associated with heroin users seeking needles: “They constantly go to pharmacies … [in turn, the pharmacies] said they got so tired of finding needles in the bathroom they said they’re only giving them to regular customers.” Heroin use continues to span a wide range of individuals. Both participants and community professionals reported heroin use among white adult males and females, Hispanics, suburbanites, young whites aged 15-25 years, opiate users and older users who have been addicted for years. One participant said, “[A typical heroin user is] 14 [years of age] and up. I say mostly white people. I do see a handful of black people but they’re older - like from Ray Charles’ era, from back in the bluesy times when [using heroin] wasn’t so big and those are the lifers.” Other participants commented: “The biggest thing I see is suburban people. It’s a lot of middle class using heroin; Suburban kids. It’s their brother or their friend who does [heroin].” Many participants noted that dealers of heroin are more likely to be black, but users are more likely to be white. A participant reflected, “Predominantly black males that sell [heroin], but I’ve seen all different types of races using it.” A treatment provider said, “I see a lot of young white girls who are using [heroin] for the first time, using it intravenously because of their boyfriends’ [use].” Prescription Opioids Prescription opioids remain highly available in the region. Participants most often reported the current availability of these drugs as ‘10’ on a scale of ‘0’ (not available, impossible to get) to ‘10’ (highly available, extremely easy to get); the previous most common score was also ‘10.’ A participant commented, “You can get [pills] with a couple of phone calls.” Community professionals most often reported current availability as ‘7;’ the previous most common score was ‘10.’ Participants and community professionals identified Percocet® and Vicodin® as the most popular prescription opioids in terms of widespread use, followed by OxyContin® OPs, oxycodone (“Perk 30s”) and Opana®. Several participants agreed, “’Perks’ and ‘Vikes’ (Vicodin®) are easiest to get.” An officer also reported, “All the heroin addicts we get are still … requesting perks or vikes or whatever they can get [from doctors].” Participants continued to report higher difficulty in obtaining “premium” prescription opioids such as Dilaudid®, fentanyl, crushable Opana® and morphine. Page 86 One participant reported, “[My dealer] could get crushable [opioid pills] easily, but not within the last six months.” Corroborating data also indicated the presence of prescription opioids in the region. American Court and Drug Testing Services reported that 8.7 percent of the 971 individuals screened through its Medina lab during the past six months were positive for oxycodone. Media outlets reported on law enforcement seizures of prescription opioids in the region this reporting period, as well as prescription fraud and the use of the Ohio Automated Rx Reporting System (OARRS) to stop doctor shopping. Reportedly, prescription (“script”) drug rings are a growing crime; typically a ring leader will enter a legitimate occupation as a low level employee in a medical facility and steal prescription pads and then recruit people to fill fraudulent prescriptions at various pharmacies (www.wkyc.com, Feb. 8, 2014). The Ohio State Highway Patrol (OSHP) arrested a man in Geauga County after finding over 80 prescription opioid pills in his vehicle, as well as approximately 70 benzodiazepine pills, eight prescription stimulant pills and a small amount of marijuana (www.statepatrol.ohio.gov, March 24, 2014). Several Elyria (Lorain County) police units worked together and conducted a spring roundup targeting narcotics dealers; 21 arrests were made and police seized 220 doses of oxycodone and Opana®, 160 grams of cocaine, 30 grams of heroin, 270 grams of marijuana and nine doses of ecstasy/MDMA (www. wkyc.com, April 8, 2014). A 51-year old man was reported as doctor shopping in Westlake (Cuyahoga County) when the hospital staff checked the OARRS system and found that the man obtained prescriptions through 56 doctors and 18 pharmacies in the past year; hospital staff alerted police (www. cleveland.com, May 14, 2014). A Medina County resident was robbed of her medication when she excused herself to use the restroom while talking to a newspaper solicitor (www. cleveland.com, June 6, 2014). A woman from North Ridgeville could not adequately explain to Westlake hospital staff why she had been prescribed 120 pain pills the previous month, so they contacted the police to check pharmacy records; the city prosecutor is considering charging the woman with attempted deception to obtain prescription drugs (www. cleveland.com, June 11, 2014). There was no consensus among participants regarding a change in availability of prescription opioids during the past six months. Participants who discussed decreased availability commented: “The doctors are cutting them off [not writing prescriptions for these pills]; People started OSAM Drug Trend Report January-June 2014 Surveillance of Drug Abuse Trends in the Cleveland Region getting mad when they ‘proofed’ (reformulated pills to make them more tamper resistant) because they don’t work as well; My doctor won’t give [prescription opioids] to me because of my drug history.” Other participants commented that these pills are still readily available. Prescription Opioids Community professionals reported that availability has increased during the past six months. A diversion officer described changes in the availability of these pills in the region: “I’ve seen a really big push in ‘perk 10s’ (Percocet® 10 mg) . . . We’ve gotten [intercepted] packages through the mail of the Roxicodone® ‘15s and 30s’ (15 mg and 30 mg) … A lot of pharmacies don’t carry them because they don’t like that risk . . .Dilaudid® is hot [popular], as an injectable out of medical facilities. We’re getting a couple complaints a month now … Vicodin® has stayed the same, but Percocet® has jumped two or three times the amount.” The BCI Richfield Crime Lab reported that the number of prescription opioid cases it processes has remained the same during the past six months. Reported Availability Change during the Past 6 Months Participants No Consensus Law enforcement Increase Treatment providers Increase Prescription Opioids Reportedly, many different types of prescription opioids are currently sold on the region’s streets. Current street prices were consistent among participants with experience buying prescription opioids. Participants reported the following prescription opioids as available to street-level users. A participant noted, “’Perk’ (Percocet®) is more wanted than Vicodin®. People are willing to pay a higher price.” Current Street Prices for Prescription Opioids fentanyl $1-1.25 per mcg Opana® $1.50-3 per mg OxyContin® OP $0.20-0.50 per mg Prescription opioids remain highly available through doctors, friends, family members and occasionally from dealers. A participant discussed obtaining prescription opioids from doctors: “For me, I always got them from my doctor, then I moved and got them again and it was easy [because] I got referred to another doctor for something with my back ….” Participants also discussed obtaining these pills from pill mills. One participant explained: “It’s all in the suburbs, cash doctors all over the place. Mentor, Willoughby, Cleveland Heights. I know a lot of people who will go to a doctor to get pills to sell to a dealer or sell themselves.” While there were a few reported ways of consuming prescription opioids, the most common route of administration remains oral consumption. Participants estimated that out of 10 illicit prescription opioid users, five would take the drugs by mouth (including crushing, wrapping in tissue and swallowing, “parachuting”), four would snort and one would intravenously inject the drugs. A participant noted that pills with certain ingredients, like acetaminophen, would not be suitable for snorting and commented, “It depends on the pill. For example, I’ve never seen anyone snort a Vicodin®.” A treatment provider also observed, “For the heroin addict you’re going to go to extremes to use [prescription opioids – typically injected if at all possible]. Casual users just ‘pop’ (use orally).” A profile of a typical illicit user of prescription opioids did not emerge from the data. Several participants agreed that these drugs are consumed by all types of people. Other participants described illicit user groups to include heroin addicts and people (under the age of 25 years). Another participant added, “The injured person keeps about three pills for themselves and sells the rest.” Law enforcement identified prescription opioid users as heroin addicts and dealers, higher socio-economic status and people in labor intensive occupations. An officer explained, “In my experience, it’s heroin addicts. When they can’t get heroin or before they start using heroin.” An officer added, “A lot of the dealers are users as well and we see the heroin and the prescription pills with them.” Another officer shared, “I see a lot of the affluent suburbs and the richer white kids [abusing prescription opioids]. And it’s all the way into the high schools. They start out on pills and then they get into heroin.” Percocet® $1 per mg Roxicodone® $1 per mg Vicodin® $0.50 per mg 2013 OSAM Drug Trend Report January-June 2014 Page 87 Page 8 Surveillance of Drug Abuse Trends in the Cleveland Region Corroborating data also indicated the presence of Suboxone® in the region. American Court and Drug Testing Services reported that 6.7 percent of the 971 individuals screened through its Medina lab during the past six months were positive for buprenorphine, an ingredient in Suboxone®. In addition, media outlets reported on law enforcement seizures of Suboxone® in the region this reporting period. OSHP seized 123 Suboxone® strips and three Suboxone® pills, 78 grams of heroin and two grams of crack cocaine after pulling a vehicle over in Cuyahoga County for driving left-of-center (www.statepatrol.ohio.gov, Jan. 21, 2014). Participants reported that the availability of Suboxone® has increased during the past six months. Participants attributed increased availability to pain management clinics which are now prescribing Suboxone® to patients. One participant shared knowledge of Suboxone® pill-mill type operations and explained, “It’s all cash doctors, no insurance and they are moveable. They rent out a random store front and they’re here this day and this day and that day and it’s all cash - then they’re out. It’s just Suboxone® … It’s not part of a program at all, you just show up, pay cash and leave.” Community professionals also reported that availability has increased during the past six months and attributed the increase to increased number of prescriptions being written and the overall increase in heroin use. A treatment provider said, “Now that they’re covered under Medicaid they can find doctors to prescribe [Suboxone®] if they have the money. They get it through pain management, too, though not a lot.” Page 88 Suboxone® Suboxone® remains highly available in the region. Participants reported the current street availability of Suboxone® as ‘10’ on a scale of ‘0’ (not available, impossible to get) to ‘10’ (highly available, extremely easy to get); the previous most common score was ‘8.’ Participants agreed with a participant who commented, “’Strips’ (Suboxone® sublingual film form) are more available than [tablet form].” A participant added, “I haven’t seen the pills for two or three years. I’ve only seen the strips.” Community professionals most often reported current availability as ‘7;’ the previous most common score was ‘10.’ A law enforcement officer commented, “[Users] just go to their doctor and they say they’re trying to get off heroin and they get it just like that. Then they got [Suboxone®] and they sell it.” Another officer remarked, “They trade [drugs] back and forth - for this or that. [Suboxone®] does have a high value to it.” The BCI Richfield Crime Lab reported that the number of Suboxone® cases it processes has increased the same during the past six months. Reported Availability Change during the Past 6 Months Participants Increase Law enforcement Increase Treatment providers Increase Street prices for Suboxone® were consistent among participants with experience buying the drug. A participant commented, “ [Suboxone® and Subutex® pills and strips] are available if you have money.” Suboxone® Suboxone® Current Street Prices for Suboxone® Any form (film or tablet; Suboxone® or Subutex®) $15-25 for 8 mg Participants shared that Suboxone® continues to be primarily obtained by prescription from drug abuse treatment centers and pain management clinics. Participants also reported acquiring this drug from friends and dealers, particularly connected with heroin. Participants and community professionals indicated this drug is commonly abused. A participant admitted, “The only time I got [Suboxone®] was from my [heroin] dealer.” Another participant explained, “I’ve never had a Suboxone® prescription from a doctor, but I know there are many that are available now to write a prescription. I always got mine from friends.” Participants reported that the most common route of administration of Suboxone® is sublingual; however, several participants explained that Suboxone® pills can be crushed and injected. Participants also reported preference for the pill form because they do not have tracking numbers on them like the strips do. Participants estimated that out of 10 illicit Suboxone® users, eight would sublingually use as directed and two would intravenously inject (“shoot”) the drug. A participant explained the various forms and preferred administration of this drug, “I think the Subutex® is better than Suboxone® because you can still get high on them. You can crush them and shoot them. You can’t snort the strips, but you need hot water and you can shoot them.” OSAM Drug Trend Report January-June 2014 Law enforcement suggested typical illicit users of Suboxone® are most often heroin addicts who are self-medicating through heroin withdrawal. A law enforcement officer explained, “They’re not getting high from Suboxone® like heroin. They’re using [Suboxone®] to get through the period when they don’t have heroin.” Sedative-Hypnotics Sedative-hypnotics (benzodiazepines, barbiturates and muscle relaxants) are moderately available in the region. Participants most often reported the current availability of these drugs as ‘10’ on a scale of ‘0’ (not available, impossible to get) to ‘10’ (highly available, extremely easy to get); the previous most common score was ‘7.’ Participants identified, Klonopin®, Valium® and Xanax® as the most popular sedative-hypnotics in terms of widespread use. Several participants agreed, “Xanax® is it … and it’s easier to get now.” Community professionals most often reported current availability as ‘7;’ the previous most common score was ‘10.’ Community professionals identified Xanax® as the most popular sedative-hypnotic in terms of widespread use. A law enforcement officer commented, “Xanax® is as available as ‘perk’ (Percocet®) and Vicodin®. It goes hand-in-hand. If you’re selling pills or diverting pills, you’re going to be diverting Xanax® because people want it. Xanax® is at the top of the list.” A treatment provider explained that doctor prescribing is one reason Xanax® is so popular and commented, “Anytime you go to the doctor and you say, ‘I have anxiety.’ They try to give you Xanax®.” Corroborating data also indicated the presence of sedativehypnotics in the region. American Court and Drug Testing Services reported that 5.7 percent of the 971 individuals screened through its Medina lab during the past six months were positive for benzodiazepines. Participants reported that the overall availability of sedative-hypnotics has remained the same during the past six months, while community professionals indicated increased availability, especially with Xanax®. A law enforcement officer specifically observed, “Ambien® and the sleeping aids have gone way up [in availability].” The BCI Richfield Crime Lab reported that the number of sedative-hypnotic cases it processes has remained the same during the past six months. 2013 OSAM Drug Trend Report January-June 2014 SedativeHypnotics Surveillance of Drug Abuse Trends in the Cleveland Region Reported Availability Change during the Past 6 Months Participants No Change Law enforcement Increase Treatment providers Increase Reportedly, a few different types of sedative-hypnotics are currently sold on the region’s streets. Participants reported that sedative-hypnotics generally sell for between $2-5 per pill, with slightly higher pricing for brand names instead of generics and for higher milligram dosage ($10-12, reported for 2 mg Xanax®). Other pills in this category sell for much less or are traded freely. A participant said, “Klonopin®, Ativan®, Soma®, Neurontin®, Seroquel® - they sell for about 50 cents a pill. That’s like bumming a cigarette.” Participants most often reported obtaining sedative-hypnotics from doctors, friends and family members. These drugs were not commonly obtained from street-level drug dealers. A participant explained, “Xanax® is the easiest one to get from doctors and from dealers.” While there were a few reported ways of consuming sedative-hypnotics, and variations in methods of use were noted among types of sedative-hypnotics, generally the most common route of administration remains oral consumption (“popping”). Oral consumption reportedly includes chewing the pill or wrapping in tissue and swallowing it (“parachuting”). Participants estimated that out of 10 illicit sedative-hypnotics users, approximately seven would orally ingest, two would snort and two would intravenously inject (“shoot”) the drugs. Reportedly, snorting or shooting are more common when sedative-hypnotics are used in combination with other drugs. Participants described typical illicit users of sedative-hypnotics as drug addicts and people who have anxiety. A participant said, “My doctor prescribed me Xanax® and methadone for like a year. When I wanted to detox it took me 40 days because I was detoxing from benzos and opiates at the same time.” Treatment providers identified typical illicit users of sedative-hypnotics as ranging from 20s to 50s in age, more often female and persons who have insurance. A treatment professional reported, “It’s young females who get [sedative-hypnotics] from psychiatrists. The doctor doesn’t know that they’re shooting a gram of heroin a day, either.” Another treatment provider disclosed, “I have a lot of friends who are upper middle class, who don’t think of themselves as addicts. They take Ambien®, Xanax®, Klonopin® every night of their life and think nothing Page 89 Page 8 Surveillance of Drug Abuse Trends in the Cleveland Region of it. People are totally in denial and that’s the wealthier white population [who are dependent on sedative-hypnotics].” Marijuana Marijuana remains highly available. Participants and community professionals continued to most often report the current availability of marijuana as ‘10’ on a scale of ‘0’ (not available, impossible to get) to ‘10’ (highly available, extremely easy to get); the previous most common scores were also ‘10’ for both respondent groups. Higher quality marijuana is the most available type of marijuana throughout the region. Participants commented: “I couldn’t get ‘reggie’ (regular, low-grade marijuana) if I tried … It’s just ‘kush’ (high-grade marijuana) and better kush; Reggie is a bit harder to find. People don’t want it and the dealers make more money off ‘loud’ (high-grade marijuana).” A treatment provider made a similar observation and commented, “That’s right, [high-grade marijuana is] all we hear. We don’t hear about regular marijuana anymore.” Marijuana concentrates and extracts are also available throughout the Cleveland region. Participants familiar with these forms of marijuana rated current availability most often as ‘10.’ Marijuana concentrates and extracts reference products derived from medicinal alchemy of marijuana: an extraction of tetrahydrocannabinol (THC) from high-grade marijuana leaves by heating it with butane and creating a brown, waxy, hard substance. These concentrates are known to contain over 90 percent THC. One participant claimed, “I’ve made butane hash oil before. It’s pretty easy to get.” Treatment providers indicated that there needs to be a social connection to obtain these THC products, as one treatment provider commented, “You need to know people that can do it (are able make the concentrate).” Corroborating data also indicated the presence of marijuana in the region. American Court and Drug Testing Services reported that 17.9 percent of the 971 individuals screened through its Medina lab during the past six months were positive for marijuana. Media outlets reported on law enforcement seizures of marijuana in the region this reporting period. OSHP arrested an Oregon man in Lorain County after they stopped him for a moving violation and discovered 32 pounds of marijuana in his vehicle (www.statepatrol.ohio.gov, Jan. 21, 2014). A man was taken from Cleveland’s west side (Cuyahoga County) to the hospital for injuries after a marijuana grow operation and lab exploded and set fire to Page 90 the building; police seized evidence including four butane tanks which were used to extract cannabis oil from the plant for making marijuana concentrates (www.impact. cleveland.com, Jan. 29, 2014). The South East Area Law Enforcement (SEALE) narcotics unit (Cuyahoga County) targeted marijuana being delivered in the area via postal services; more than 50 pounds of the substance was seized (www.impact.cleveland.com, Feb. 11, 2014). A man was arrested in Cleveland after police found seven ounces of marijuana, a digital scale, a gun and cash in a child’s gym bag in his vehicle (www.statepatrol.ohio.gov, March 10, 2014). South Euclid (Cuyahoga County) police found nearly 28 grams of marijuana inside an SUV following a high-speed chase (www.impact.cleveland.com, March 19, 2014). Cleveland police were called to a house to investigate a sound complaint and found a marijuana grow operation; they seized over 50 plants (www.cleveland.com, March 31, 2014). South Euclid Police arrested a man after finding 153 grams of marijuana in his car after they pulled him over for driving at night without using headlights (www.cleveland.com, May 16, 2014). A 19-year-old was punched in the face and choked when he went to meet three people to purchase marijuana (www.cleveland.com, May. 19, 2014). OSHP troopers located 1.5 pounds of highgrade marijuana inside the rear cargo area of a vehicle after a K-9 officer alerted to the vehicle during a traffic stop (www.statepatrol.ohio.gov, May 21, 2014). Participants reported that the availability of low-grade marijuana has remained the same or has decreased during the past six months, while noting that high-grade marijuana availability has increased during the same time period. Participants remarked upon the increasing availability of high-grade marijuana due to the proximity of states where marijuana is legal. A participant observed, “It used to be … ‘reggie’ (regular, low-grade marijuana) was everywhere. You couldn’t get any ‘kind bud’ (high-grade marijuana). Now you can’t find any reggie. It’s all high end coming from states where it’s all medical.” Additionally, participants reported increasing availability of marijuana concentrates during the past six months. Participants attributed the increased availability of this drug, in part, to the increased availability of tools and equipment to create and consume the product. A participant explained, “There’s a new tool to smoke the ‘earwax’ (marijuana concentrate). They have connectors for bongs now - it’s a piece of metal, like a nail head and you hit it with the butane and you put a little glass globe with a hole in the top and heat it.” Another participant said, “You can buy extractors now, oil extractors, it does it for you.” OSAM Drug Trend Report January-June 2014 Surveillance of Drug Abuse Trends in the Cleveland Region Reported Availability Change during the Past 6 Months Participants Increase Law enforcement Increase Participants continued to rate the overall current quality of marijuana as ‘10’ on a scale of ‘0’ (poor quality, “garbage”) to ‘10’ (high quality); the previous most common score was also ‘10.’ A participant explained, “Even the ‘regs’ (regular low-grade marijuana) that do come around are good [quality] … The weed that’s around is such high quality.” Most participants rated the quality of marijuana extracts as ‘10.’ Participants and community professionals remarked on how potent these extracts are. A participant said, “You only need a couple hits and you’ll be out of your mind.” A law enforcement officer explained, “It’s super [potent] marijuana.” Participants reported that marijuana concentrate is not cut or adulterated with any other substance. The price of marijuana depends on the quality desired; current street prices for marijuana were consistent among participants with experience buying the drug. Participants did not provide specific pricing for low-grade marijuana, but commented that it sells for about half as much as high-grade marijuana. An officer commented, “’Mexican brown’ (low-grade marijuana) is sold by the pound, there are bales of it.” Current street prices for marijuana concentrates and extracts were reportedly high among participants with experience buying the drug and depends on the cost of the marijuana needed to produce the product. A participant explained, “My friend wouldn’t sell the oil. It’s very labor intensive. That’s why you get a bunch of guys together to throw in their bags [of marijuana] and then you all just blast it [with butane to make the extract] and sit around and do ‘dabs’ (hash oil) all night.” Current Street Prices for Marijuana Treatment providers Increase Reported Availability Change during the Past 6 Months Participants No Consensus Law enforcement No change Treatment providers No Change Marijuana Low Grade Marijuana High Grade Marijuana Community professionals reported that the availability of low-grade marijuana has remained the same during the past six months, while noting that high-grade marijuana availability has increased. A law enforcement officer said, “The high quality medical [marijuana] is out there because of all the source states. You can go to the post office and pull 30 boxes off the line every day. The postal inspectors are looking for other stuff, but there’s so much ‘weed’ (marijuana) ... sticky bud, pharmaceutical, the expensive stuff.” Law enforcement also reported an increase in marijuana concentrates and extracts during the past six months. A law enforcement officer said, “We’re starting to see so much of it … Two months ago I got an alert about this drug and that week we grabbed three packages coming through the mail.” Another officer reported, “I talked to a fireman who said they used to have a lot more explosions because of the meth labs, but they’re seeing a lot more because of the hash oil and the extraction process.” Additionally, an officer related recent experience and commented, “We never heard of this stuff a year ago ... most of the [marijuana extractions] we’ve seen around here have been people making it for themselves, not selling it.” The BCI Richfield Crime Lab reported that the number of marijuana cases it processes has remained the same during the past six months. High-grade: A blunt (cigar) or $10 two joints (cigarettes) 1/4 ounce $80-100 An ounce $200 A pound $5,000-6,000 Concentrates/extracts: 1/2 gram $60 A gram $80-120 The most common and only route of administration for marijuana reported by participants remains smoking. Participants estimated that out of 10 marijuana concentrate 2013 OSAM Drug Trend Report January-June 2014 Page 91 Page 8 Surveillance of Drug Abuse Trends in the Cleveland Region users, all of them would smoke the drug, most typically using a vaporizer device. A participant said, “When I’ve smoked it looked like an e-cigarette. You can’t even tell [the difference]. It’s a little vial with some liquid in it….” Another participant shared, “It’s vaporized basically … It’s as much THC as you can possibly get.” A profile for a typical marijuana user did not emerge from the data. Universally, respondents felt marijuana use to be widespread. A treatment provider remarked on how marijuana is consistently the most identified drug of use by clients during intake interviews despite any demographic. Participants and law enforcement described typical concentrate and extract users as marijuana connoisseurs. A law enforcement officer commented, “[Dabs] is for people who are really into weed, people who love it.” Methamphetamine Methamphetamine is highly available in the region. Although most participants did not have experience with this substance, the participants who did most often reported the drug’s current availability as ‘10’ on a scale of ‘0’ (not available, impossible to get) to ‘10’ (highly available, extremely easy to get); the previous score was ‘3.’ Participants reported lowest availability in the urban center. A participant shared, “[Methamphetamine] is so easy to get [on the far east side].” Another participant said, “Meth and heroin are the biggest thing in Lake County. You need to know somebody. It’s not really a party drug. You have to make a chain of phone calls.” Additionally, a participant explained that once you know someone who makes methamphetamine, it is very easy to obtain the drug. Participants reported that the most common type of methamphetamine in the region is powdered (“shake-andbake” or “one-pot”). Reportedly, this form is easily and quickly produced, as fewer ingredients are required. It is produced in a single sealed container, such as a two-liter soda bottle by using common household chemicals along with ammonium nitrate (found in cold packs) and pseudoephedrine (typically found in some allergy medications). The production of about 2 grams can be produced in 30-45 minutes using this shakeand-bake method. In regards to the higher grade, lab created, crystal-like methamphetamine a participant remarked, “Maybe once in a blue moon you see the lab stuff.” Community professionals most often reported the current availability of methamphetamine as ‘1;’ The previous Page 92 most common score was ‘4.’ However, treatment providers noted that participants report high availability of methamphetamine, but clients who are addicted to methamphetamine rarely pass through treatment facilities. A treatment provider disclosed, “I’ve worked 26 years in the [alcohol and other drug] field and I’ve never worked with a meth addict.” Another treatment provider commented, “I don’t see [meth addiction] a lot. I go to a ton of AA and NA meetings and talk with a lot of people and I’m just not hearing it. I have a niece in West Virginia and in the mountains it’s rampant, but not here. What’s blowing my mind is that I don’t see it.” Media outlets reported on law enforcement seizures of methamphetamine in the region this reporting period. A man hid a woman with several warrants out for her arrest in the attic above his parent’s garage (Cuyahoga County); both were arrested after police were called and signs of meth labs were found in the attic and garage (www.cleveland.com, Jan. 8, 2014). Medina County Drug Task Force seized eight portable labs in a home and five people were arrested; further investigation reported a number of people come from Summit County to Medina County to buy pseudoephedrine to make the drug (www.cleveland.com, March 3, 2014). Four individuals were arrested in Geauga County when a narcotics raid uncovered six pounds of methamphetamine worth over $600,000 along with 100 pounds of marijuana, a kilo of black tar heroin and a vial of steroids; reportedly this was the largest number of illegal drugs seized at one time in the county’s recent history (www.cleveland.com, June 16, 2014). Participants reported that the availability of methamphetamine has increased during the past six months and purported that heroin and methamphetamine trafficking are now interrelated. Treatment providers suggested no change in methamphetamine availability during the past six months. The BCI Richfield Crime Lab reported that the number of methamphetamine cases it processes has increased during the past six months; the lab reported processing offwhite powder and some crystal methamphetamine. Of the few participants who commented on the current overall quality of methamphetamine, they rated it as ‘5-7’ on a scale of ‘0’ (poor quality, “garbage”) to ‘10’ (high quality). A participant shared that powdered, home-made methamphetamine contains, “whatever’s under the kitchen sink.” When asked about other substances used to cut methamphetamine, a participant explained, “You don’t need to cut meth.” OSAM Drug Trend Report January-June 2014 Methamphetamine Surveillance of Drug Abuse Trends in the Cleveland Region Reported Availability Change during the Past 6 Months Participants Increase Law enforcement No Comment Treatment providers No Change Current street prices for methamphetamine were consistent among participants with experience buying the drug; a gram sells for $50-60. Participants noted that methamphetamine dealers will often accept chemical components used to make the drug. as payment for either methamphetamine or heroin. A participant explained, “I used to buy Sudafed® [to trade] for heroin.” Another participant explained, “Yep, you can get $50 of meth or heroin for a box of Sudafed®.” Generally participants reported obtaining methamphetamine from outside the region in adjacent OSAM regions: Akron-Canton and Youngstown. While there were a few reported ways of consuming methamphetamine, the most common route of administration is smoking, followed by snorting and intravenous injection (“shooting”). Out of 10 methamphetamine users, participants estimated that approximately four would smoke, three would shoot and three would snort the drug. A participant explained, “Older people smoke and younger people shoot.” Participants described typical methamphetamine users as white, rural, males and females. Participants shared: “[Methamphetamine is] for hillbillies; It’s out in the country; I’ve seen more [40-year olds and older] smoking meth.” A participant commented about race, “I’ve never seen a black person use meth.” Additionally, participants suggested crack cocaine dealers and incarcerated individuals would be more likely to use methamphetamine. Participants commented: “I was in jail and there were a lot of people who were doing [methamphetamine]; My old dealer would do crystal meth to stay up and sell crack.” Prescription Stimulants According to the few participants who had recent experience with these drugs, prescription stimulants remain highly available in the region. Participants reported the 2013 OSAM Drug Trend Report January-June 2014 current availability of prescription stimulants as ‘9’ or ‘10’ on a scale of ‘0’ (not available, impossible to get) to ‘10’ (highly available, extremely easy to get); the previous most common score was ‘10.’ Community professionals were unable to comment about the illicit use of this drug as they do not encounter it often. According to participants, Adderall® is the most available prescription stimulant throughout the region. A participant stated, “Adderall® is most prevalent. It used to be that Ritalin® was most popular, but then Adderall® took over.” Participants reported increased availability of prescription stimulants during the past six months. A participant reasoned, “More people are getting diagnosed ADHD, so there [are] more [prescription stimulant prescriptions] out there. It seems like anyone that walks in and says they have trouble concentrating can get it.” The BCI Richfield Crime Lab reported that the number of prescription stimulant cases it processes has remained the same during the past six months. Participants did not have much pricing information and said most prescription stimulants sell for $1-5 per pill. A participant shared that Adderall® 30 mg sells for approximately $8. Participants continued to report obtaining prescription stimulants most often from people with prescriptions, diversion from children’s prescriptions and from obtaining prescriptions from doctors. The most common route of administration for prescription stimulants remains oral consumption. A participant explained, “Nobody snorts the Adderall® extended release pills. They have those beads inside for delayed release.” Participants described typical illicit users of prescription stimulants as younger, female and cocaine addicted. Other user groups included people illicitly using the drugs to improve productivity. A participant commented, “[Prescription stimulants] are used by people studying.” Bath Salts Bath salts (synthetic compounds containing methylone, mephedrone or MDPV) remain available in the region. Although few participants had recent experience with bath salts, they reported them as highly available in the region. Of participants who were able to comment on bath salt availability, they most often reported current availability as ‘10’ on a scale of ‘0’ (not available, impossible to get) to ‘10’ (highly available, extremely easy to get); the previous most Page 93 Page 8 Surveillance of Drug Abuse Trends in the Cleveland Region Bath Salts Participants reported that the availability of bath salts has either remained the same or has slightly decreased during the past six months. A participant reasoned that availability has slightly decreased because, “If you go into any head shop [to buy bath salts] and they don’t know you, they act like SWAT is behind you.” A treatment provider also reported that availability has decreased and explained, “From what I hear, [bath salts] was easy to get, but now it’s more difficult.” The BCI Richfield Crime Lab reported that the number of bath salts cases it processes has increased during the past six months. Reported Availability Change during the Past 6 Months Participants No Consensus Law enforcement No Comment Treatment providers Decrease Two participants reported the current quality of bath salts as ‘10’ on a scale of ‘0’ (poor quality, “garbage”) to ‘10’ (high quality), while another participant reported the quality as ‘7’ on the same scale; the previous most common quality score was ‘10.’ A participant said, “All it is now is research chemicals like mephedrone, and you can order that online 99 percent pure.” Participants with knowledge of this drug reported that the overall quality of bath salts has decreased during the past six months. One participant explained, “Quality is going down because they keep changing the analogs … I was a bath salts freak. I did everything and anything I could have wanted. The shit [you purchase online] sucks. . . .” A participant reported that a vial (approximately 1 gram) sells for about $30. Participants reported purchasing bath salts at corner stores or online. A participant described purchasing the product, “It’s usually in a package like when you buy those caffeine pills, and then inside is a clear glass vial with a cap. Or, it’s round like a lip balm. It’s cheap.” Page 94 Participants reported the most common route of administration for bath salts is snorting. Participants estimated that out of 10 bath salt users, five would snort, three would smoke and two would intravenously inject the drug. A participant described smoking bath salts: “I know people who buy [bath salts] online, then they soak it [in] acetone, then they put it on potpourri. You can smoke it. It’s not in the stores, it’s something you buy. It’s like ‘Spice’ (synthetic marijuana) and bath salts had a baby.” Participants and treatment providers described typical bath salts users as whites and young people. Several participants discussed how bath salts do not appeal to most poly-drug users. One participant commented, “[Bath salts use is] like a meth high and a coke high at the same time. You’re trapped in this bizarre mind thing and it’s terrible.” A treatment provider recalled, “I had some clients at my last job who used [bath salts]. They were white and young.” Synthetic Marijuana Synthetic marijuana (synthetic cannabinoids; “K2” and “Spice”) remains available in the region. Participants most often reported the current availability of the drug as ‘7’ on a scale of ‘0’ (not available, impossible to get) to ‘10’ (highly available, extremely easy to get); the previous most common score was ‘10.’ A participant reported, “You can’t really get [synthetic marijuana] in the stores, but online it’s a ‘10.’” Community professionals did not rate the availability of synthetic marijuana; the previous most common score was ‘10’ by law enforcement. However, a treatment provider reported, “I hear about K2 a lot.” Participants reported that the availability of synthetic marijuana has decreased during the past six months. Community professionals did not provide comment as to availability change for synthetic marijuana during the past six months. The BCI Richfield Crime Lab reported that the number of synthetic marijuana cases it processes has remained the same during the past six months. Synthetic Marijuana common score was ‘3.’ Participants shared that availability would be highest for people who have a direct connection with local corner store owners and sales people, as the sale of bath salts is typically hidden. A participant explained, “It’s probably an ‘8’ [on the availability scale] if you look real hard. I know a couple stores that put [bath salts] out through people. I’ve heard that as long as you know people you can get them. You can get them online, too.” Treatment providers continued to rate bath salt availability as ‘2;’ the previous score was also ‘2.’ Reported Availability Change during the Past 6 Months Participants Decrease Law enforcement No Comment Treatment providers No Comment OSAM Drug Trend Report January-June 2014 Surveillance of Drug Abuse Trends in the Cleveland Region Two participants rated the current quality of synthetic marijuana as ‘5’ or ‘10’ on a scale of ‘0’ (poor quality, “garbage”) to ‘10’ (high quality). However, several participants indicated that the quality of synthetic marijuana continues to decline. A participant explained, “When [synthetic marijuana] first came out, it was pretty strong, but it got weaker.” Several participants reported that the drug’s high no longer delivers an experience like THC or authentic marijuana. Participants commented: “[Synthetic marijuana] started out like THC and now it’s taken a wrong turn; It’s very different than it used to be. It’s also very addicting and you do go through withdrawal.” A participant shared an experience with the substance, “I’ve seen squirrels running around my apartment. It’s like tripping on a bad trip of acid - It’s more like bath salts … you’re standing outside your body. It’s really weird.” Prices for synthetic marijuana were variable among participants experienced with purchasing the drug. Several participants shared that a gram sells for between $10-20, while other participants reported purchasing synthetic marijuana for as little as $25 for 3 grams. Still another participant reported 1/8 ounce sells for $15-20. Participants shared that synthetic marijuana is only obtained through Internet purchase. A participant remarked, “I couldn’t get [synthetic marijuana] in any stores … I couldn’t even get it off the streets from people. You can still get it online.” Participants reported smoking as the only route of administration for synthetic marijuana. One participant added, “There was this stuff called ‘JWH-018’ (a specific synthetic cannabinoid sold online) and I freebased it. It was like a pen. They use ‘AM2201’ (another synthetic cannabinoid sold online) now. There are still some ‘AM’s’ (AM series of cannabinoids) that aren’t illegal yet.” Participants and treatment providers described typical users of synthetic marijuana as people who are on probation, in a drug use monitoring program or in the military. A treatment provider commented, “[Synthetic marijuana is] kind of an issue at the halfway house. I haven’t seen anyone with it, but it’s an issue there because it doesn’t show up in tests, so they try to get away with something.” 2013 OSAM Drug Trend Report January-June 2014 Ecstasy Ecstasy (methylenedioxymethamphetamine: MDMA, or other derivatives containing BZP, MDA, and/or TFMPP) remains highly available in the region. Participants reported the most popular form of the drug is the loose powder that is purported to be pure MDMA known as “molly.” Participants most often reported the current availability of molly as ‘9’ on a scale of ‘0’ (not available, impossible to get) to ‘10’ (highly available, extremely easy to get); the previous most common score for ecstasy tablets was ‘10.’ A participant commented, “I’ve heard of [molly] and it’s out there. I know people around my neighborhood that have gotten it and sell it.” Another participant clarified, “’Real molly’ (pure MDMA) is a ‘2,’ but ‘fake’ (adulterated) molly with bath salts is ‘10.’” Community professionals rated the current availability of ecstasy tablets as ‘2;’ the previous score was variable between ‘2’ and ‘10.’ Treatment providers commented on the perceived high availability of molly: “It’s very easy to get [molly]; I’ve heard about it from people. At my hospital I assess all the patients that come in with dual diagnosis and in my assessments I’d have to say that 50 percent of the people have at least tried molly.” Nevertheless, a law enforcement officer reported, “We’ve only seen a little bit of molly here. It’s popped up but we’ve only seen it a couple times.” Media outlets reported on law enforcement seizures of ecstasy in the region this reporting period. After a long investigation, two area students in Berea (Cuyahoga County) received mandatory prison time for stealing supplies from a chemistry lab on campus and making ecstasy in an empty dorm room for distribution (www.cleveland.com, Jan. 15, 2014). Participants reported that the availability of molly has remained the same during the past six months. On the other hand, community professionals reported that molly availability has increased. A treatment provider commented, “I think [molly is] more available because I’ve heard about it more and I never used to hear about it.” The BCI Richfield Crime Lab reported that the number of ecstasy cases it processes has remained the same during the past six months. Page 95 Page 8 Reported Availability Change during the Past 6 Months Participants No Change Law enforcement Increase Treatment providers Increase Participants most often rated the current quality of molly as ‘4’ on a scale of ‘0’ (poor quality, “garbage”) to ‘10’ (high quality); the previous most common quality score was ‘10.’ A participant explained variability in quality of the drug: “I’ve had some [molly] that was poor [quality] and ‘cut’ (adulterated with other substances) and then I’ve had it really good. It’s hit or miss.” Another participant shared their experiences with this drug: “I’ve had pure molly, called sassafras, it’s a tan color - it smells like licorice. You only need a little bit to get high for hours.” A couple participants suggested that quality depends on where one purchases the drug and one commented, “I’ve gotten drugs from the east side and west side and anything I’ve gotten from a rich neighborhood on the west side is phenomenally better than anything on the east side … I don’t know why.” Although molly is often sold as a “pure” form of MDMA, several participants related that the powder is most often cut with other substances, such as bath salts, cocaine and methamphetamine. A participant explained, “There’s fake stuff [molly] that has chemicals and bath salt and research drugs [cut into the molly] and it’s speed and it’s not an ecstasy feeling - it’s meth that got sold as molly.” Another participant disclosed, “I do a lot of cocaine and powder is easy to get and the same dealers have molly, too. Often they say it is molly, but it is really cocaine or crushed up meth.” Another participant suggested that the high demand and profit of molly has resulted in decreased quality and remarked, “There’s so many people trying to sell [molly], so they just put a bunch of stuff together [and sell it as molly].” Reportedly, ecstasy in tablet form is sold as small pressed colored pills featuring stamped logos or images, while “molly” is typically sold as a yellowish loose powder. Traditionally, ecstasy was sold in different strengths as single, double and triple stacks; currently, a participant explained, “Single stacks or double stacks are just a myth. That’s the dealer feeding you a myth … ‘Stacks’ mean nothing whatsoever. I’ve paid for the amount [of ecstasy] that’s in the pill, not Page 96 double or whatever.” Molly is available as loose powder in a baggie, by weight or in gelatin capsules. Current street prices for ecstasy and molly were consistent among participants with experience buying the drugs. Current Street Prices for Ecstasy Ecstasy/Molly Ecstasy/Molly Surveillance of Drug Abuse Trends in the Cleveland Region Tablet form $20 per pill Current Street Prices for Molly 2/10 gram $10-20 A gram $120-150 Participants reported that the most common place to obtain ecstasy or molly remains nightclubs, strip clubs and rave (dance party) scenes. A participant disclosed, “The guy I know that has [ecstasy/molly] goes to clubs to get rid of it.” Participants reported that the most common routes of administration for ecstasy/molly are oral consumption and snorting. Participants estimated out of 10 ecstasy/molly users, five would orally ingest, four would snort and one would intravenously inject the drug. Other reported methods of administration included vaginal or anal absorption. Participants described typical ecstasy/molly users as people who like hallucinogens as well as young club goers. Participants also indicated that both blacks and whites use molly and that users are typically more affluent. A participant stated, “[Ecstasy/molly is] for people that like psychedelics, ‘acid’ (LSD) and ‘shrooms’ (psilocybin mushrooms).” Community professionals also linked ecstasy/molly use to young individuals who are more often white. Treatment providers commented: “It’s the young people that are doing [ecstasy/molly] regularly; It’s the white kids who say they’re doing it.” Other Drugs Participants and community professionals mentioned DMT (dimethyltryptamine, a hallucinogen) as another drug present in the region, but this drug was not mentioned by the majority of people interviewed. Participants reported moderate availability of DMT and most often rated its current availability as ‘7’ on a scale of ‘0’ (not available, impossible to get) to ‘10’ (highly available, extremely easy to get). Participants did not discuss quality or indicate that DMT is adulterated with any other substances. Par- OSAM Drug Trend Report January-June 2014 Surveillance of Drug Abuse Trends in the Cleveland Region ticipants suggested decreased DMT availability during the past six months. The BCI Richfield Crime Lab reported that the number of DMT cases it processes has remained the same during the past six months. DMT is typically sold as a loose powder and sells for approximately $60 per gram. Participants suggested typical DMT users are more often young and in a social setting. A participant said, “With those drugs it’s very social, you just throw money on the table [and take the drug].” Media outlets also reported on law enforcement seizures of a variety of other drugs in the region this reporting period, including psilocybin mushrooms, steroids and powdered caffeine. Medina County sheriff’s officers arrested a man following a search warrant of his home where they found a grow operation in a bedroom and seized 24 containers of psilocybin mushroom spores which were just beginning to grow, prescription medications and 27 marijuana plants (www.newsnet5.com, Feb. 7, 2014). A man was pulled over and arrested in North Royalton (Cuyahoga County) for driving under a suspended license and having syringes and testosterone enanthate (steroids) in his possession (www.cleveland.com, Feb. 28, 2014). A Lorain County high school student died of caffeine overdose following the ingestion of powdered caffeine just days before he was to graduate; powdered caffeine can be very potent and is most often ordered online (www.cleveland.com, June 30, 2014). The BCI Richfield Crime Lab reported that the number of LSD (lysergic acid diethylamide) and psilocybin mushroom cases it processes has remained the same during the past six months; the lab did not report cases of anabolic steroids. Conclusion Crack cocaine, ecstasy, heroin, marijuana, prescription opioids and Suboxone® remain highly available in the Cleveland region; also highly available in the region is methamphetamine. Changes in availability during the past six months include increased availability for heroin, marijuana and Suboxone® and likely increased availability for ecstasy (molly) and sedative-hypnotics. Participants noted fewer differences in heroin availability between the west and east sides of the city of Cleveland than previously, reporting that heroin is everywhere. Community professionals continued to cite heroin as the 2013 OSAM Drug Trend Report January-June 2014 most available drug in the region. While many types of heroin are currently available in the region, participants and community professionals continued to report powdered heroin as the most available type. Law enforcement reported that gray-colored heroin is more available than it’s ever been in the city and throughout Cuyahoga County. The BCI Richfield Crime Lab reported that the number of powdered heroin cases it processes has increased during the past six months; the lab reported processing primarily white, brown and gray powdered heroin. Participants and community professionals agreed that powerful economic forces are driving the increase in heroin availability. Despite law enforcement activity, there seems to be a limitless network of heroin and dealers. Participants and community professionals also further discussed fentanyl cut heroin. Treatment providers observed that fentanyl in heroin seems to be a trend. Both respondent groups expressed concern about how frequently overdose occurs. Heroin use continues to span a wide range of individuals. Participants attributed increased Suboxone® availability to pain management clinics which are now prescribing the drug to patients. Community professionals also attributed the increase in Suboxone® availability to increased number of prescriptions being written as well as the overall increase in heroin use. In addition to obtaining Suboxone® by prescription from drug abuse treatment centers and pain management clinics, participants reported acquiring this drug from friends and dealers, particularly connected with heroin. Participants and community professionals indicated that Suboxone® is commonly abused. Participants and community professionals reported that the availability of low-grade marijuana has remained the same or has decreased during the past six months, while noting that high-grade marijuana availability has increased. Participants remarked upon the increasing availability of high-grade marijuana due to the proximity of states where marijuana is legal. Reportedly, higher quality marijuana is the most available type of marijuana throughout the region. Participants commented that regular low-grade marijuana cannot be found. Additionally, participants reported increasing availability of marijuana concentrates during the past six months. Marijuana concentrates and extracts reference products derived from an extraction of tetrahydrocannabinol (THC) from high-grade marijuana leaves by heating it with Page 97 Page 8 Surveillance of Drug Abuse Trends in the Cleveland Region butane and creating a brown, waxy, hard substance. These concentrates are known to contain very high THC content. Participants attributed the increased availability of this drug, in part, to the increased availability of tools and equipment to create and consume the extracted product. Participants and community professionals remarked on how potent these extracts are. Participants reported that the availability of methamphetamine has increased during the past six months and purported that heroin and methamphetamine trafficking are now interrelated. Generally participants reported obtaining methamphetamine from outside the region in adjacent OSAM regions: Akron-Canton and Youngstown. Participants estimated that out of 10 marijuana concentrate users, all of them would smoke the drug, most typically using a vaporizer device. Universally, respondents felt marijuana use to be widespread. A treatment provider remarked on how marijuana is consistently the most identified drug of use by clients during intake interviews despite any demographic. Participants and law enforcement described typical concentrate and extract users as marijuana connoisseurs. Lastly, ecstasy remains highly available in the region. Participants reported the most popular form of the drug is the loose powder that is purported to be pure MDMA known as “molly.” Although molly is often sold as a “pure” form of MDMA, several participants related that the powder is most often cut with other substances, such as bath salts, cocaine and methamphetamine. Participants reported that the most common place to obtain ecstasy or molly remains nightclubs, strip clubs and rave (dance party) scenes. Participants described typical ecstasy/molly users as people who like hallucinogens as well as young club goers. Page 98 OSAM Drug Trend Report January-June 2014