George J. Unick

Intertwined Epidemics: National Demographic Trends in Hospitalizations for Heroin- and Opioid-Related Overdoses, 1993–2009

The historical patterns of opiate use show that sources and methods of access greatly influence who is at risk. Today, there is evidence that an enormous increase in the availability of prescription opiates is fuelling a rise in addiction nationally, drawing in new initiates to these drugs and changing the geography of opiate overdoses. Recent efforts at supply-based reductions in prescription opiates may reduce harm, but addicted individuals may switch to other opiates such as heroin. In this analysis, we test the hypothesis that changes in the rates of Prescription Opiate Overdoses (POD) are correlated with changes in the rate of heroin overdoses (HOD). ICD9 codes from the Nationwide Inpatient Sample and population data from the Census were used to estimate overall and demographic specific rates of POD and HOD hospital admissions between 1993 and 2009. Regression models were used to test for linear trends and lagged negative binomial regression models were used to model the interrelationship between POD and HOD hospital admissions. Findings show that whites, women, and middle-aged individuals had the largest increase in POD and HOD rates over the study period and that HOD rates have increased in since 2007. The lagged models show that increases in a hospitals POD predict an increase in the subsequent years HOD admissions by a factor of 1.26 (p<0.001) and that each increase in HOD admissions increase the subsequent years POD by a factor of 1.57 (p<0.001). Our hypothesis of fungibility between prescription opiates and heroin was supported by these analyses. These findings suggest that focusing on supply-based interventions may simply lead to a shift in use to heroin rather minimizing the reduction in harm. The alternative approach of using drug abuse prevention resources on treatment and demand-side reduction is likely to be more productive at reducing opiate abuse related harm.

Assessing recovery of people with serious mental illness: development of a new scale.

OBJECTIVES The authors describe the development of the Maryland Assessment of Recovery in People with Serious Mental Illness, or MARS, a 25-item self-report instrument that measures recovery of people with serious mental illness, and report a study of its psychometric properties. METHODS Doctoral-level scientists with expertise in serious mental illness drafted a set of survey items about the recovery process. Items reflected recovery domains outlined by the Substance Abuse and Mental Health Services Administration. After consultation with a panel of experts on recovery that included consumers and clinical scientists and with a small group of consumers, the instrument was narrowed to 67 items and administered to 166 individuals recruited from outpatient mental health clinics in two states. Item response theory and classical item analysis were used to select best-fitting items, reduce item redundancy, and improve the psychometric properties of the scale. Principal components analysis and confirmatory factor analysis were conducted to further examine dimensions of recovery measured by the scale. RESULTS The MARS is quite practical for use with individuals with serious mental illness. It demonstrated excellent internal consistency (Cronbachs α=.95) and test-retest reliability (r=.898) and good face and content validity. CONCLUSIONS The data provide initial support for use of the MARS to measure recovery of people with serious mental illness.

Factors affecting psychiatric inpatient hospitalization from a psychiatric emergency service

OBJECTIVE As a gateway to the mental health system, psychiatric emergency services (PES) are charged with assessing a heterogeneous array of short-term and long-term psychiatric crises. However, few studies have examined factors associated with inpatient psychiatric hospitalization following PES in a racially diverse sample. We examine the demographic, service use and clinical factors associated with inpatient hospitalization and differences in predisposing factors by race and ethnicity. METHOD Three months of consecutive admissions to San Franciscos only 24-h PES (N = 1,305) were reviewed. Logistic regression was used to estimate the associations between demographic, service use, and clinical factors and inpatient psychiatric hospitalization. We then estimated separate models for Asians, Blacks, Latinos and Whites. RESULTS Clinical severity was a consistent predictor of hospitalization. However, age, gender, race/ethnicity, homelessness and employment status were all significant related to hospitalization. Alcohol and drug use were associated with lower probability of inpatient admission, however specific substances appear particularly salient for different racial/ethnic groups. DISCUSSION While clinical characteristics played an essential role in disposition decisions, these results point to the importance of factors external to PES. Individual and community factors that affect use of psychiatric emergency services merit additional focused attention.

Impact of South American heroin on the US heroin market 1993-2004

BACKGROUND The past two decades have seen an increase in heroin-related morbidity and mortality in the United States. We report on trends in US heroin retail price and purity, including the effect of entry of Colombian-sourced heroin on the US heroin market. METHODS The average standardized price (

Urban segregation and the US heroin market: A quantitative model of anthropological hypotheses from an inner-city drug market

/mg-pure) and purity (% by weight) of heroin from 1993 to 2004 was from obtained from US Drug Enforcement Agency retail purchase data for 20 metropolitan statistical areas. Univariate statistics, robust Ordinary Least Squares regression and mixed fixed and random effect growth curve models were used to predict the price and purity data in each metropolitan statistical area over time. RESULTS Over the 12 study years, heroin price decreased 62%. The median percentage of all heroin samples that are of South American origin increased an absolute 7% per year. Multivariate models suggest percent South American heroin is a significant predictor of lower heroin price and higher purity adjusting for time and demographics. CONCLUSION These analyses reveal trends to historically low-cost heroin in many US cities. These changes correspond to the entrance into and rapid domination of the US heroin market by Colombian-sourced heroin. The implications of these changes are discussed.

The relationship between US heroin market dynamics and heroin‐related overdose, 1992–2008

BACKGROUND We hypothesize that the location of highly segregated Hispanic and in particular Puerto Rican neighborhoods can explain how Colombian-sourced heroin, which is associated with a large-scale decade long decline in heroin price and increase in purity, was able to enter and proliferate in the US. METHODS Our multidisciplinary analysis quantitatively operationalizes participant-observation ethnographic hypotheses informed by social science theory addressing complex political economic, historical, cultural and social processes. First, we ethnographically document the intersection of structural forces shaping Philadelphias hypersegregated Puerto Rican community as a regional epicenter of the US heroin market. Second, we estimate the relationship between segregation and: (a) the entry of Colombian heroin into the US, and (b) the retail price per pure gram of heroin in 21 Metropolitan Statistical Areas. RESULTS Ethnographic evidence documents how poverty, historically-patterned antagonistic race relations, an interstitial socio-cultural political and geographic linkage to both Caribbean drug trafficking routes and the United States and kinship solidarities combine to position poor Puerto Rican neighborhoods as commercial distribution centers for high quality, low cost Colombian heroin. Quantitative analysis shows that heroin markets in cities with highly segregated Puerto Rican communities were more quickly saturated with Colombian-sourced heroin. The level of Hispanic segregation (specifically in cities with a high level of Puerto Rican segregation) had a significant negative association with heroin price from 1990 to 2000. By contrast, there is no correlation between African-American segregation and Colombian-sourced heroin prevalence or price. CONCLUSION Our iterative mixed methods dialogue allows for the development and testing of complex social science hypotheses and reduces the limitations specific to each method used in isolation. We build on prior research that assumes geographic proximity to source countries is the most important factor in determining illicit drug prices and purity, while we find more complex, potentially modifiable determinants of geographic variation in retail drug markets. We show that specific patterns of ethnic segregation, racism, poverty and the political economy of socio-cultural survival strategies combined to facilitate the entry of pure, inexpensive Colombian-sourced heroin.

The entry of Colombian-sourced heroin into the US market: The relationship between competition, price, and purity

BACKGROUND AND AIMS Heroin-related overdose is linked to polydrug use, changes in physiological tolerance and social factors. Individual risk can also be influenced by the structural risk environment including the illicit drug market. We hypothesized that components of the US illicit drug market, specifically heroin source/type, price and purity, will have independent effects on the number of heroin-related overdose hospital admissions. METHODS Yearly, from 1992 to 2008, Metropolitan Statistical Area (MSA) price and purity series were estimated from the US Drug Enforcement Administration data. Yearly heroin overdose hospitalizations were constructed from the Nationwide Inpatient Sample. Socio-demographic variables were constructed using several databases. Negative binomial models were used to estimate the effect of price, purity and source region of heroin on yearly hospital counts of heroin overdoses controlling for poverty, unemployment, crime, MSA socio-demographic characteristics and population size. RESULTS Purity was not associated with heroin overdose, but each

US regional and demographic differences in prescription opioid and heroin-related overdose hospitalizations

100 decrease in the price per pure gram of heroin resulted in a 2.9% [95% confidence interval (CI) = 4.8%, 1.0%] increase in the number of heroin overdose hospitalizations (P = 0.003). Each 10% increase in the market share of Colombian-sourced heroin was associated with a 4.1% (95% CI = 1.7%, 6.6%) increase in number of overdoses reported in hospitals (P = 0.001) independent of heroin quality. CONCLUSIONS Decreases in the price of pure heroin in the United States are associated with increased heroin-related overdose hospital admissions. Increases in market concentration of Colombian-source/type heroin is also associated with an increase in heroin-related overdose hospital admissions. Increases in US heroin-related overdose admissions appear to be related to structural changes in the US heroin market.

Developing an instrument to measure organizational trauma-informed care in human services: The TICOMETER.

There have been large structural changes in the US heroin market over the past 20 years. Colombian-sourced heroin entered the market in the mid-1990s, followed by a large fall in the price per pure gram and the exit of Asian heroin. By the 2000s, Colombian-sourced heroin had become a monopoly on the east coast and Mexican-sourced heroin a monopoly on the west coast with competition between the two in the middle. We estimate the relationship between these changes in competitive market structure on retail-level heroin price and purity. We find that the entry of Colombian-sourced heroin is associated with less competition and a lower price per pure gram of heroin at the national level. However, there is wide variation in changes in market concentration across the US. Controlling for the national fall in the heroin price, more competition in a region or city is associated with a lower price per pure gram.

Illness Severity and Psychiatric Hospitalization Rates Among Asian Americans and Pacific Islanders

BACKGROUND US opioid overdose death rates have increased between 2000 and 2014. While, the increase in prescription opioid use has been linked to the increase in heroin use, there are reasons to view this relationship as a partial explanation for the recent increase in heroin-related harms. This study documents the differences in trends in prescription opioid overdose-related (POD) and heroin overdose-related (HOD) hospitalizations. METHODS Data come from the National Inpatient Sample (NIS) for the years 2000 through 2014. POD and HOD hospitalizations were abstracted from ICD-9 codes. Rates of POD and HOD by census region and census division were constructed along with separate rates for age and race. Regression analysis analyzing trends across region were estimated along with graphs for documenting differences in POD and HOD rates. RESULTS POD hospitalization rates were highest in the South and lowest in the Northeast. HOD hospitalization rates were highest in the Northeast region and grew the fastest in the Midwest. There was statistically significant heterogeneity in HOD trends but not POD trends across the four regions between 2000 and 2014. Between 2012 and 2014 POD rates decreased in eight of the nine census divisions, with only New England showing an increase. HOD hospitalization rates increased in all nine census divisions between 2012 and 2014. Both POD and HOD rates show different demographic patterns across the nine census divisions. CONCLUSION Comparing POD and HOD hospitalization trends reveals significant disparities in geographic as well as demographic distributions. These epidemics are evolving and the simple opioid-to-heroin transition story is both supported and challenged by this paper. The opioid pill, heroin and fentanyl crises are intertwined yet increasingly have drivers and outcomes that support examining them as distinct. Addressing these complex and interrelated epidemics will require innovative public health research and interventions which need to consider local and regional contexts.