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Kentucky Drug Threat Assessment
Other Dangerous Drugs
Other dangerous drugs, especially diverted pharmaceuticals, club drugs, and hallucinogens, are an increasing threat to Kentucky. Pharmaceutical diversion investigations were once limited to individuals but now include multiperson enterprises. The number of treatment admissions in Kentucky for abuse of oxycodone--mostly OxyContin and Percocet--increased 163 percent from fiscal year 1998 through fiscal year 2000. The increased level of diverted pharmaceutical distribution and abuse has become so significant that the Kentucky Cabinet for Health Services developed computer software to help physicians, pharmacists, and law enforcement authorities identify patterns of abuse. The abuse of hallucinogens such as ketamine, LSD, and psilocybin mushrooms and of club drugs, especially GHB and MDMA, is increasing. Club drugs and hallucinogens are popular at raves and dance clubs where the drugs are readily available and frequently abused. Peer pressure and cultural myths surrounding the use of club drugs continue to undermine the warnings of healthcare professionals regarding the serious side effects associated with these drugs.
The diversion of prescription painkillers is recognized by law enforcement agencies throughout Kentucky as an increasing threat, especially in eastern portions of the state. While the scope of diversion investigations was once limited to individual abusers, targets now include multiperson enterprises. Pharmaceutical diversion now involves huge profits and large quantities of drugs being siphoned from legitimate sources. The number of diverted pharmaceuticals has become so significant that the Kentucky Cabinet for Health Services developed computer software to identify potential abuse patterns.
The abuse of pharmaceuticals is a significant problem in Kentucky. In eastern areas of the state, the abuse of pharmaceuticals, particularly OxyContin, has reached alarming levels. While most pharmaceuticals are ingested orally, some users inject drugs such as methadone, OxyContin, and Dilaudid exposing themselves to the risks associated with intravenous drug use.
From FY1998 through FY2000, treatment for the abuse of prescription drugs accounted for 20 percent of all treatment admissions in the state. Male abusers of pharmaceuticals outnumber female abusers four to one in Kentucky. The state ranks third in the nation for per capita consumption of hydrocodone and codeine products. According to the Kentucky Division of Substance Abuse, the most widely abused prescription drug categories during FY2000 (in order of prevalence) were alprazolam (Xanax), oxycodone (OxyContin), diazepam (Valium), hydromorphone hydrochloride (Dilaudid), methadone hydrochloride (methadone), codeine phosphate/sulfate (codeine), and amphetamine sulfate (amphetamine).
Prescription drugs are diverted by a number of means such as prescription forgeries, pharmacy burglaries, armed robberies, employee theft, and doctor shopping--a practice in which a patient visits multiple physicians to acquire numerous prescriptions. Diverted pharmaceuticals are transported into Kentucky by couriers, in private vehicles, or via package delivery services. Most pharmaceutical diversion involves a collection of individuals rather than organized groups working in concert. In Louisville in February 2000, undercover agents purchased more than 8,100 morphine, Dilaudid, and methadone tablets sold by an Ohio pharmacy employee. The diverted tablets had an estimated street value of $25 to $75 per dosage unit. In May 2001 a federal grand jury in Lexington indicted seven people on charges that they used home computers to forge prescriptions for OxyContin. The individuals scanned a legitimate prescription into a computer, altered it, and printed the copy on an ink jet printer. The individuals passed more than 30 forged prescriptions, and police estimate that more than 2,000 OxyContin tablets were obtained for use and distribution using this method. In February 2000 an eastern Kentucky police chief was arrested for acting as a lookout in pharmacy burglaries in which hydrocodone and diazepam were specifically targeted.
In the eastern coal mining counties of Kentucky, the large-scale diversion and abuse of painkillers are particular problems. In the past coal miners spent hours each day crouched in narrow mine shafts. Painkillers were dispensed by coal mine camp doctors in an attempt to keep the miners working. Self-medicating became a way of life for miners, and this practice often led to abuse and addiction among individuals who would have been disinclined to abuse traditional illicit drugs.
Legislative efforts have also been made to monitor the diversion of prescription drugs in Kentucky. In 1998 Kentucky passed legislation that requires the use of prescription paper with security features for all controlled substances. The legislation also includes the monitoring of veterinary prescriptions. This safeguard, which has proven to be effective in decreasing written forgeries, has precipitated an increase in attempted fraudulent prescriptions phoned in to pharmacies. Physicians with questionable prescribing habits in Kentucky's interstate border locations have advised patients to fill their prescriptions in neighboring states to avoid detection.
Over the years the retail sale of diverted pharmaceuticals has progressed from individual addicts concerned only with their daily supplies to individuals working together to sell large quantities on the street, from vehicles, or from private residences. Some individuals recruit known or potential patients and use several vehicles to transport the patients to several doctors in many communities in a single day or week to conduct large-scale doctor shopping sprees. It is not uncommon for spouses or domestic partners to work together to commit prescription fraud and to sell the drugs.
There are some reports that suggest a connection between cannabis cultivation and the financing of pharmaceutical diversion. Law enforcement reports indicate that individuals in eastern Kentucky are using proceeds from marijuana sales to purchase large quantities of diverted pharmaceuticals.
Alprazolam, also known commercially as Xanax, is a benzodiazepine-type depressant used as an antianxiety tranquilizer. Benzodiazepines were first marketed in the 1960s as antianxiety medications and initially were believed to have fewer adverse side effects than other depressants such as barbiturates. Benzodiazepines affect the central nervous system, have potent hypnotic and sedative qualities, and often are abused in combination with alcohol, heroin, or cocaine to alter the side effects associated with narcotic withdrawal or overstimulation. According to the Kentucky Division of Substance Abuse, Xanax was the most widely abused prescription drug during FY2000. According to a survey of Kentucky State Police jurisdictions, the statewide average price for alprazolam was $2 per tablet in 2000.
Another form of benzodiazepine popular in Kentucky is diazepam, also known commercially as Valium. It is a depressant with effects that are long-lasting. Both alprazolam and diazepam have ranked among the top four drugs for pharmaceutical drug abuse treatment in Kentucky since 1997. Nationally, approximately 50 percent of individuals entering treatment for narcotic or cocaine addiction also report abusing benzodiazepines.
Oxycodone, an opiate agonist, is known commercially as OxyContin, Percocet, Percodan, and Tylox. Opiate agonists provide pain relief by acting on opioid receptors in the spinal cord and brain. Opioids are synthetic drugs that act like morphine and are the most effective pain relievers available. Oxycodone is manufactured by modifying thebaine, an alkaloid found in opium. Oxycodone is prescribed for moderate to severe pain associated with injuries, bursitis, dislocations, fractures, neuralgia, arthritis, back ailments, and cancer. It also is used postoperatively and for pain relief after childbirth.
Oxycodone-related deaths in Kentucky have increased significantly since 1998. From January 2000 through May 2001, the Kentucky State Medical Examiner's Office identified the presence of oxycodone in 69 deaths; the oxycodone levels were toxic in 36 of those deaths. OxyContin is one of the most abused oxycodone products in Kentucky. During 2000 the Pike County Coroner recorded 19 OxyContin-related deaths. Emergency room visits and deaths in eastern Kentucky attributed to OxyContin have increased significantly in the past 2 years. According to law enforcement, seven OxyContin-related overdose deaths occurred in southeastern Kentucky during December 2000.
The abuse of oxycodone products such as OxyContin has become so prevalent that officials in Kentucky are describing it as an epidemic. The number of patients seeking treatment for oxycodone addiction in Kentucky increased 163 percent, from 103 patients in FY1998 to 134 patients in FY1999 and to 271 patients in FY2000. By October 1999 several physicians had established pain clinics in southeastern Kentucky and were writing several hundred prescriptions for OxyContin on a daily basis. The Kentucky State Police report that OxyContin is more popular than cocaine in eastern portions of the state.
Abusers administer oxycodone using various means; the most dangerous is by intravenous injection. Intravenous administration involves combining crushed OxyContin tablets with water and injecting the mixture. Other abusers rub off the controlled-release coating on the tablets, crush them, and snort the powder. In eastern Kentucky abusers often have white streaks on their blue jeans indicating that they have been rubbing the coating off OxyContin tablets. Abusers sometimes use OxyContin as a suppository.
In some parts of Kentucky, OxyContin sells for $25 per 20-milligram tablet. Individuals who are prescribed OxyContin for a legitimate medical condition may sell portions of their prescription to retail distributors in order to supplement their income. According to a survey of Kentucky State Police jurisdictions, the statewide average street price for OxyContin is $1 per milligram. Users and distributors also obtain OxyContin by stealing the drug from pharmacies--Kentucky is one of the leading states for OxyContin-related robberies and burglaries. Between January 2000 and June 2001, 69 of the state's 1,000 pharmacies reported OxyContin-related burglaries or robberies.
Hydromorphone hydrochloride, known commercially as Dilaudid, is an organic compound of morphine and is classified as an opioid. As a pain reliever, it is two to eight times as potent as morphine. Abusers often dissolve the tablets and inject them as a substitute for heroin. Use of hydromorphone in Kentucky has diminished slightly, although it remains one of the top five most commonly abused prescription drugs in Kentucky. According to a survey of the Kentucky State Police, the statewide average street price was $30 per tablet in 2000.
Methadone hydrochloride, known commercially as Dolophine, is a synthetic opioid used primarily for the management of heroin and narcotic addiction at treatment centers. It is used to help alleviate the symptoms of narcotic addiction withdrawal. It is primarily administered as a liquid at treatment centers but is also available as a tablet. The tablet is designed to deter abuse via intravenous injection. However, the tablets are much easier to conceal and abuse than the liquid form. (Patients are usually required to ingest the methadone in the clinic while under observation.) Although it is closely regulated, illegal use is common. Methadone may be abused in combination with clonazepam or other benzodiazepines in order to enhance its narcotic effect. In eastern Kentucky 10-milligram methadone tablets are ground and dissolved in water before being drawn through a cigarette filter or similar filtering device; the drug then is injected intravenously. Cities with methadone treatment centers such as Bowling Green, Lexington, and Louisville, as well as those in neighboring states, are known as areas where diverted methadone and heroin transactions occur.
The effects of methadone last 24 hours before the drug is expelled from the body. Individuals may unintentionally overdose on methadone because they do not realize that the residual chemicals remain in the body long after the drug's intended effects have subsided. Abusers often ingest one drug after another until toxic levels build and respiratory failure, coma, or death occurs. As many as seven different pharmaceuticals have been detected in the blood of some methadone overdose victims in eastern Kentucky. In the fall of 2000, six individuals died from methadone overdoses in Breathitt County alone.
The abuse of club drugs, especially GHB and MDMA, is increasing, particularly among young people. A resurgence in the availability of some hallucinogens--LSD, PCP (phencyclidine), psilocybin, and peyote or mescaline--at raves and dance clubs nationwide is also a concern. The perception by young people that these substances are harmless has led to increased levels of use. Peer pressure and cultural myths surrounding club drugs continue to undermine the warnings of healthcare professionals regarding the serious side effects associated with these drugs, and some individuals in Kentucky have become habitual, daily abusers. National statistics document a sharp increase in the use of club drugs--a trend just beginning in Kentucky. Although there are no specific statistics on club drug abuse treatment or arrests in Kentucky, several drug task forces report that MDMA, GHB, and LSD abuse and distribution by college students are increasing throughout Kentucky. The Kentucky State Police in Bowling Green reports an increase in MDMA and GHB abuse, primarily on a local university campus. Officials expect a similar increase in club drug abuse among local high school students near college and university centers.
Many users are experimenting with an extremely dangerous combination of club drugs, other illicit drugs, and alcohol. The wide range of drugs available at raves and parties provides opportunities for the dangerous use of drugs in combination--for example, MDMA and heroin or MDMA and peyote or mescaline, which some agencies refer to as new age speedballs.
Rave parties and clubs are focal points for the rave culture and the distribution of club drugs in Kentucky; however, club drugs are distributed in all metropolitan areas and college communities throughout Kentucky and have recently been sold in smaller towns and cities across the nation. The schedule for raves closely follows the college semester cycle. Very few raves were held during times when colleges and universities were not in session. From 1993 through 2001 there were more than 146 documented raves held in Kentucky. Most took place in Louisville and Lexington. Other locations include Bowling Green, Covington, Erlanger, Murray, and Newport. In 1993 there was only one recorded rave in Louisville; by 1999 the number of raves had increased to 23 per year. From 1993 through 2000, 82 raves were held in Louisville, accounting for more than 50 percent of all known rave activity in Kentucky. These numbers reflect only the raves that are documented; undoubtedly, there were many more raves that avoided law enforcement detection because the very essence of the underground rave culture is based upon spontaneity and secrecy.
MDMA. The availability and abuse of MDMA have increased in Kentucky. Also known as ecstasy, XTC, E, X, or Adam, MDMA is a synthetic, psychoactive substance with stimulant and mild hallucinogenic properties. MDMA is taken orally, usually in tablet form, and its effects last approximately 4 to 6 hours. If taken in tablet or capsule form, the onset of effects takes approximately 30 to 45 minutes; if snorted, smoked, or injected, effects are immediate. Known as the hug drug or feel good drug, MDMA reduces inhibitions and produces feelings of empathy for others, extreme relaxation, and the elimination of anxiety. In addition to chemical stimulation, the drug reportedly suppresses the need to eat, drink, or sleep. This enables users who frequent the club scene to endure all-night and sometimes 2- to 3-day parties or raves. The drug often leads to severe dehydration and heat stroke since it has the effect of short-circuiting the body's temperature signals to the brain. An MDMA overdose is characterized by a rapid heartbeat, high blood pressure, faintness, muscle cramping, panic attacks, and in more severe cases, loss of consciousness or the onset of seizures. Users risk exhaustion from a combination of the drug's effects and the physical exertion of all-night dancing. The National Institute on Drug Abuse findings indicate that long-term use of MDMA causes significant, irreparable damage to the brain.
MDMA availability is increasing, primarily in Kentucky's urban areas; however, there is no evidence of increasing violent behavior associated with MDMA abuse in Kentucky. Violence typically is not associated with MDMA because it often creates increased feelings of friendship and compassion.
Although some MDMA production occurs in the United States, legislation enacted in 1990 makes it illegal to purchase or possess safrole, isosafrole, or piperonal--the primary MDMA precursors--without a permit and seems to have thwarted large-scale domestic production. There is no evidence that MDMA currently is produced in Kentucky.
Most MDMA reportedly is shipped into the United States from the Netherlands by way of Belgium and Germany. It is transported into Kentucky by couriers on airline flights originating in Europe destined for the Cincinnati/Northern Kentucky International Airport by way of California; Atlanta, Georgia; and Houston, Texas. MDMA is also transported into Kentucky from Miami, Florida.
The most common methods used to transport club drugs from other U.S. states and within the state are package delivery services, private and commercial vehicles, and public transportation. Louisville, Lexington, and Covington are major distribution centers for MDMA and other club drugs in the state.
MDMA is distributed at the wholesale and retail levels primarily by Caucasian males. The distribution process usually involves three-person teams--the first person distributes the product, the second person collects the money, and the third person waits outside the club for the money.
GHB and Analogs. The availability and abuse of GHB (gamma-hydroxybutyrate) and its analogs--GBL, BD, GHV, and GVL--also are increasing, primarily in Kentucky's urban areas.
GHB analogs are drugs that possess chemical structures that closely resemble GHB, a central nervous system depressant. GHB and its analogs are also known as liquid ecstasy, soap, scoop, Georgia homeboy, grievous bodily harm, liquid X, and goop. At lower doses they cause drowsiness, dizziness, nausea, and visual disturbances. At higher doses, unconsciousness, seizure, severe respiratory depression, and coma can occur. Because of their sedative properties, GHB and its analogs also have been used to facilitate sexual assaults throughout the nation.
GHB analogs are available at disreputable health food stores, gyms, and via the Internet. Originally sold in health stores, GHB was marketed as a releasing agent for growth hormones that would stimulate muscle growth. It is odorless, tasteless, and virtually undetectable if added to a drink. GHB is easily produced by combining GBL (gamma-butyrolactone), a chemical found in industrial cleaners and sold as a dietary supplement, with sodium hydroxide or potassium hydroxide in a cooking pot or bucket. The chemicals give off heat as they react, and the final product does not have to be isolated or separated from the solution. When ingested, GBL is converted into GHB. Lawful production of GHB occurs only in Europe. However, Internet recipes and the ease with which precursor chemicals can be legally obtained make the illicit production of GHB a potential problem in Kentucky as well as throughout the country. Most illegally produced GHB is in liquid form; the powdered form is much more difficult to synthesize and usually results only from commercial production.
The deadly consequences of GHB abuse in Kentucky became apparent in June 2000 when several young people who had visited a popular dance club in Lexington became seriously ill. It was not clear whether the individuals knew they had ingested GHB or thought they were drinking water. As a result of this incident, within a 36-hour period seven individuals were treated at a local hospital for GHB overdoses. One 27-year-old man died from a GHB overdose and a 22-year-old woman required the use of a respirator. Nationally, GHB was linked to at least 58 deaths and more than 5,700 reported overdoses from 1990 through 2000.
GHB and its analogs usually are distributed locally by the young Caucasian males who also produce GHB. They also transport it and are the primary wholesale and retail distributors of the drugs throughout the state. The ease with which GHB can be produced facilitates wholesale distribution of the drug. The retail distribution process involves three-person teams similar to those distributing MDMA. Most GHB and its analogs are distributed in liquid form at raves or on college campuses. GHB reportedly sells for $10 per capful at raves in Lexington.
Hallucinogens include a broad range of drugs that induce hallucinations. Among them are ketamine, LSD, and psilocybin--a substance found in varieties of mushrooms that are frequently referred to as magic mushrooms or psychedelic mushrooms. Hallucinogen abuse is popular and increasing among college age students, particularly at raves and dance clubs in Kentucky.
Independent producers and distributors are the primary suppliers of hallucinogens. Like club drugs, hallucinogens are distributed and used primarily by young adult Caucasians, which probably best explains the appearance of these drugs at raves in Kentucky.
Ketamine. Also known as K, special K, or cat valium, ketamine is a disassociative general anesthetic for veterinary and limited human pediatric surgical use. First produced in the 1960s, ketamine was used extensively during the Vietnam War as an anesthetic for battlefield surgery. Medically prescribed use for humans is now very limited because of the hallucinogenic side effects. The product is diverted from legitimate sources; there are no reports of illicit production. The only known source of ketamine is through diversion or theft and burglary of medical clinics.
Ketamine liquid can be injected, applied to smokable material, or consumed in drinks. The powdered form is made by allowing the solvent to evaporate, leaving a white powder that, once pulverized, looks very similar to cocaine. Ketamine produces physical effects similar to PCP with the visual effects of LSD. Users report that they prefer ketamine to PCP or LSD. Use of the drug can cause delirium, amnesia, depression, long-term memory and cognitive difficulties, and fatal respiratory problems.
Veterinarians pay $7 for a 10-milliliter vial of liquid ketamine that can be converted into a gram of powder. Diverted ketamine is sold at the wholesale level for $30 to $45 per vial and $100 to $200 for an equivalent amount at the retail level. Single ketamine doses, or bumps, of about 0.2 grams sell for $20 to $40. Ketamine usually is sold through a network of friends and associates; street sales to unknown buyers rarely occur. In June 2001 a Louisville task force seized 288 dosage units of ketamine shipped from San Diego, California, via a package delivery service to Louisville. Further investigation indicated that 10 similar shipments were made to the same individual prior to this seizure.
LSD. Also known as acid, boomers, and yellow sunshine, LSD is a hallucinogen that induces abnormalities in sensory perceptions. The effects of LSD are unpredictable and often depend on the amount taken, the environment in which it is used, and the personality, mood, and expectations of the user. The potency of the LSD available today (20 to 80 micrograms) is considerably lower than the levels of the 1960s and 1970s (100 to 300 micrograms). Users may feel the effects within 30 to 90 minutes. The physical effects include dilated pupils, sweating, loss of appetite, sleeplessness, dry mouth, tremors, and increased heart rate, body temperature, and blood pressure. LSD users report body numbness, weakness, trembling, and often nausea. Two long-term disorders associated with LSD are persistent psychosis and hallucinogen persisting perception disorder (flashbacks). LSD typically is taken orally and is sold as a tablet, capsule, or liquid as well as on pieces of paper (blotters), sugar cubes, or pieces of candy that have absorbed the drug.
LSD is available on a limited basis throughout Kentucky and is abused most frequently in urban centers, especially on college, university, and high school campuses. LSD abuse is closely associated with the abuse of other hallucinogens such as psilocybin mushrooms and with the abuse of marijuana. Statewide only a relatively small number of individuals abuse hallucinogens. LSD is readily available in the metropolitan areas of the state. Demand for LSD treatment ranked in the top 12 for illicit drug abuse in Kentucky since 1997.
The production of LSD is time-consuming and complex, requiring some degree of expertise in chemistry. The procurement of precursor chemicals required for LSD production is difficult. The primary precursor chemicals are either ergotamine tartrate or lysergic acid amide, both of which are federally regulated. LSD is produced in California and transported into Kentucky and throughout the country in liquid and blotter forms. Wholesale distributors travel to source areas such as Sacramento and San Francisco to purchase a crystallized form of LSD. The product is then transported back to the wholesale distributor's area where it is broken down into smaller amounts and sold to midlevel distributors. LSD is frequently marketed at music festivals and raves and sells for $10 per hit or dosage unit.
Psilocybin. The active ingredient in a number of mushrooms, psilocybin varies widely in potency by species. Independent growers cultivate mushrooms indoors and frequently harvest those that grow wild. Doses normally range from 20 to 60 milligrams, and the effects generally last from 5 to 6 hours. Psilocybin availability is increasing in college towns across the state.
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