St. Louis, Missouri

Drug Abuse Patterns and Trends in St. Louis, Missouri—Update: January 2014

Heidi Israel, Ph.D., A.P.N., F.N.P., L.C.S.W.

Overview of Findings: The consistently high levels for heroin indicators and the increase in indicators for both heroin and prescription opioids/opiates other than heroin relative to other drugs were key findings in the St. Louis area in the first half of 2013. An increase in methamphetamine indicators in the St. Louis region in the first half of 2013, in addition to the continuing methamphetamine presence in rural areas of the State, was also a key finding in this reporting period. During the first 6 months of 2013, heroin indicators in the St. Louis metropolitan area remained high, but anecdotal information from law enforcement sources indicated that heroin use and availability had stabilized. However, there was a slight increase in the number of primary heroin treatment admissions, compared with the first 6 months of 2012. Many of the indicators for the other major substances of abuse remained relatively stable or were trending downwards in the first half of 2013. Other drug categories have shown some decreases in numbers of primary treatment admissions, numbers and proportions of drug-related deaths, and numbers of arrests. Numbers of primary cocaine treatment admissions and proportions of cocaine-related deaths for St. Louis City and County decreased over six reporting periods (death data were for the first half of 2008 through the first half of 2013). Cocaine remained available in urban areas, according to the area representative. While alcohol was frequently indicated as a secondary drug of abuse in area indicators, proportions of treatment admissions were stable in the first half of 2013 from previous reporting periods. Amphet­amines continued be reported among drug indicators in St. Louis County and outlying counties at relatively low but gradually increasing levels, with heroin and methamphetamine prevalent according to anecdotal reports. Synthetic drugs, herbal preparations, “bath salts” (substituted cathinones), and hallu­cinogen combinations continued to be reported in poison control center calls. Prescription narcotic analgesics were reported in both the urban and suburban areas, as well as the more rural areas of the St. Louis Metropoli­tan Statistical Area (MSA). Heroin and prescription opioids as primary drug problems have overwhelmed both State and private treatment resources.

Updated Drug Abuse Trends and Emerging Patterns

Cocaine indicators continued to stabilize at a lower level in the first half of 2013, compared with the first half of 2012. The number of primary cocaine treatment admissions decreased from 1,235 in the first half of 2008, to 825 in the first half of 2009, 788 in the first half of 2010, 643 in the first half of 2011, 482 in the first half of 2012, and 481 in the first half of 2013. Cocaine remained the third most frequently identified drug in the St. Louis region among total drug reports from drug items seized and analyzed by National Forensic Laboratory Information System (NFLIS) laboratories, but cocaine represented only 10.4 percent of drug reports in the first of 2013. This proportion was relatively stable from 9.8 percent of total drug reports in the first half of 2012. While cocaine was identified as a drug problem in the St. Louis area, problems with heroin and prescription opioids/opiates other than heroin have taken attention from cocaine. Law enforcement officials reported consistent availability of cocaine in this reporting period, with stability in prices and in purity. No change in past-30-day cocaine use (2.4 percent) was noted between the 2006 and 2010 Missouri School Surveys; 2011 results for Missouri were not available at the time of this report.

Heroin: The heroin market in the St. Louis region has grown and become more complex over the past few reporting periods, and heroin indicators were increasing. Primary heroin treatment admissions increased from the first half of 2008 (n=1,088 admissions) through the first half of 2013 (n=2,274 admissions); increases were observed during each reporting period. In the first half of 2013, heroin represented the highest proportion of primary treatment admissions after alcohol, with 34.6 percent of total admissions; this was an increase from 34.2 percent of total admissions in calendar year (CY) 2012 and 31.4 percent of the total in 2011. Two types of heroin were available, primarily Mexican white heroin, with some black tar also reported. Heroin was reported by law enforcement sources to be consistently available and pure enough to both snort and inject, and it offers a cheaper alternative to the more expensive prescription opioids/opiates other than heroin. Overall, heroin-related deaths in the Missouri counties where they were monitored numbered 121 in the first half 2011 and 117 in the first half 2013, a difference that is not statistically significant. According to the area representative, an apparent leveling off in heroin-related deaths in this reporting period may partially be attributed to the fact that all ambulances in the area now carry Narcan®. Heroin represented 16.1 percent of drug reports identified among drug items analyzed in NFLIS laboratories in the first half of 2013, an increase from 13.1 percent of total drug reports in the first half of 2012. Community forums and media events have been held around the region to address the young heroin user problem.

Opioids/Opiates Other Than Heroin: The available indicators for prescription opioids/opiates other than heroin showed an increase during this reporting period. While the actual number of primary treatment admissions for these drugs was relatively low (n=254 in the first half of 2013, compared with n=212 in the first half of 2012, n=200 in the first half of 2011, n=205 in the first half of 2010, and n=157 in the first half of 2009), these drugs present reasons for multiple concerns, according to the area representative. Nearly one-quarter (24.4 percent) of these treatment admissions were younger than 24. Additionally, in the death data, 28.4 percent of primary drugs and 8.6 percent of secondary drugs present in the decedents in the first half of 2013 were prescription opioids/opiates other than heroin. People with problems with these drugs represent at least two distinct subsets of users: adolescent and young adult recreational drug users and chronic pain patients. The latter are known to be at higher risk for drug overdose. A centralized prescription monitor­ing system is not yet available in Missouri. Fentanyl, oxycodone, and hydrocodone are the frequently cited drugs in indicators, as well as the drugs reported anecdotally that clients seek in emergency rooms. There were multiple reports in this reporting period from key informants about increases in prescription drug use.

Methamphetamine indicators appeared to be slowly increasing over the last five reporting cycles. The numbers of primary methamphetamine treatment admissions decreased in the St. Louis region from the first half of 2008 (n=173) to the first half of 2009 (n=141), increased in the first half of 2010 (n=210), decreased again in the first half of 2011 (n=177), but then showed small increases in the first half of 2012 (n=210) and the first half 2013 (n=257). While numbers of clan­destine methamphetamine laboratory seizures decreased in 2013, and there were many area counties enforcing laws on amphetamine precursors, it is believed that the bulk of the available methamphetamine was being imported from Mexico. Law enforcement reports supported the increased availability of methamphetamine in the rural Midwest, and a few amphetamine-related deaths were noted in the rural medical examiner data in the first half of 2011 (n=5), in the first half of 2012 (n=9), and in the first half of 2013 (n=14). Statewide, 1,309 clandestine laboratories were reported through October 2013, and 1,744 were reported through October 2011, compared with 1,453 clandestine laboratories in 2009 and 1,487 in 2008. Methamphetamine represented 8.8 percent of all drug reports among items seized and analyzed by NFLIS laboratories in the St. Louis MSA (stable from 8.6 percent of total reports in the first half of 2012); the drug continued to rank fourth among the top 10 drugs identified by NFLIS in the first half of 2013.

Marijuana/Cannabis: Primary marijuana treatment admissions, as a percentage of total admissions, were stable for several years but decreased in the first half of 2013 (from 23.7 percent of total admissions in calendar year [CY] 2008, to 21.3 percent in CY 2009, 22.5 percent in CY 2010, 20.5 percent in CY 2011, 16.7 percent in CY 2012, and 16.5 percent in the first half of 2013). This decrease may be an arti­fact of the capped number of available slots. In the first half of 2013, 56.6 percent of these marijuana clients were younger than 25. Marijuana/cannabis was the most frequently identified substance among drug reports from drug items seized and analyzed in NFLIS laboratories in the St. Louis MSA in the first halves of 2012 and 2013.

MDMA: There were no key informant reports about availability or continued use of MDMA (3,4-methylenedioxymethamphetamine) in select populations for the first half of 2013.

Substituted Cathinones and Synthetic Cannabinoids (Cannabimimetics): Newer synthetic drug combinations and herbal preparations, “bath salt” (substituted cathinone) combinations, and hallucinogens may be sold in the St Louis area, but they were not as publicly discussed. While no deaths have been attributed to these drugs at present, local media and law enforcement have issued alerts about their availability in the region. Poison control centers reported 123 exposure calls for synthetic drugs, including substituted cathinones and synthetic cannabinoids (THC [tetrahydrocannabinol] analogs or cannabimimetics) in 2013; these numbers represented decreases from previous reporting periods. Cannabimimetics alone were reported in 149 human exposure calls to poison control centers in 2012 and in 286 exposure calls in 2011.

Alcohol remained one of the most frequent primary drug problems for clients entering publicly funded treatment pro­grams in Missouri. Proportions of primary alcohol treatment admissions showed increases through 2008, but they stabilized through the first halves of 2011, 2012, and 2013. This was potentially an artifact of a system that has been heavily impacted by heroin and stimulant drugs. Alcohol has been frequently indicated as a second­ary drug of abuse in St. Louis and Missouri drug indicators. The 2010 Missouri School Survey showed only a slight increase in past-30-day alcohol use among 6th and 12th graders from 2006 levels.

HIV (human immunodeficiency virus)/AIDS (acquired immunodeficiency syndrome) Update: St. Louis City and County continued to be ranked in the top 10 U.S. cities with reportable sexually transmitted diseases. Data available from the St. Louis City Health Department and the Missouri Department of Health and Senior Services for 2001–2012 showed overall data on 5,482 HIV disease cases in the St Louis area, with 18,915 HIV disease cases state­wide. These data indicate that the risk factor of injection drug use (4–6 percent) did not play a major role in the transmission of HIV or AIDS in the St. Louis area. Men having sex with men and heterosexual contact in minority populations were more prominent risk factors.

Summary: Indicators for many substances, including heroin, marijuana, and cocaine, appeared to be stable. However, the increase in a number of opiate indicators remained cause for concern and con­tinued monitoring. A synthesis of all data sources leads the area representative to the conclusion that drug problems with prescription opioids/opiates other than heroin were on the rise in multiple cohorts, and prescription opioids/opiates other than heroin were at a high level of availability, which makes prevention and intervention more complex. The heroin market has become more diverse, and potent drugs have become more avail­able to a wider range of users, including those living in rural areas where there are fewer resources to intervene. Methamphetamine use appears to be well-established in the area based on a review of indicators.

Emerging Patterns: The most recent additions to amphetamine-based products were substituted cathinone products. Newer, potent hallucinogens have media and law enforcement attempting to identify the level of availability of these products. These new drugs will be followed by poison control centers and toxicologists.

Data Sources: Analysis of drug trends for the St. Louis region requires multiple data sources; a number of sources were used for this report. Missouri Treatment Episode Data Set admissions for the first 6 months of CYs 2008–2013 provided invaluable indicators for treatment data. The January–June 2013 NFLIS reports for the St. Louis MSA provided forensic data and offered a unique view of drug trends for a variety of substances. The Missouri Department of Health and Senior Services provided HIV/AIDS data for fiscal years 2006–2012, and the local St. Louis City Health Department provided measures of HIV/AIDS and other data by risk factor that are helpful in understanding the role of injection drug use on health. Missouri School Survey data for 2006–2010 gave a glimpse of general youth trends in current and lifetime use of some of the major substances, although no new data for 2011 were available. Drug-related death data from the St. Louis City and County Medical Examiner for the first 6 months of CY 2008 through the first half of 2013 provided insight into the extent that drug use may result in death, along with basic demographic data helpful to understanding emerging trends. Ongoing reports of drug use, price, and purity data from the Drug Enforcement Administration and the National Drug Intelligence Center are invaluable, as are the frequent formal written reports and anecdotal insight provided by the staff of these agencies. Information on availability was provided by local law enforcement officials. Poison control center data came from the Missouri Poison Center.