Well, greetings everyone. My name is Anthony Decker. I'm a osteopathic physician. I'm currently the chief medical officer for the division of developmental disabilities in Phoenix, Arizona for the state of Arizona. Topic today is the 2023 new drugs on the street. And we'll be going over several things in this process. From a disclosure standpoint, I've presented numerous programs on chronic pain management, addiction medicine, and previous medical review officer courses. This program stresses only my opinions and they are not necessarily the opinions of my previous employers, which included the state of Arizona, the Veterans Administration, the Department of Defense, the Indian Health Service or the US Public Health Service. So I do not represent any state or federal agency in this capacity. I have no conflicts to report. Objectives for this program are to present an overview for new psychoactive substances of abuse and new delivery systems that are active in 2023, to describe pharmacologic properties of some of the medications, to describe intoxication and the adverse effects of some of these substances, and to review monitoring issues for these substances. The 2022 National Forensic Laboratory Information System. It is a report that is from a government service. In addition, seven narcotic analgesics were among the top 25 drugs that were detected. So the NFLIS is a collection of both federal and state and private labs throughout the country that test for a variety of substances of abuse. So fentanyl was seen in 153,000, almost 154,000 reports. Everyone's aware that between October 21 to October 22, there were 107,000 deaths secondary to drug overdoses of which over 82% of those were secondary to fentanyl. Oxycodone was seen in 15,000 reports. Buprenorphine also seen in 15,000 reports. I should add that buprenorphine is an immune receptor agonist, it's a partial agonist, but it is also a medication that can be used, misused or abused. And many people keep buprenorphine to treat their opioid withdrawal, but it's not physician or provider monitored care. Tramadol was seen in almost 15,000 reports. Fluorofentanyl was seen in 10,000 reports. Parafluorofentanyl a little over 7,000 and hydrocodone in nearly 7,000 reports. There were five tranquilizers and depressants including the most commonly seen L-Prazolam, almost 17,500. Xylazine, which is a derivative of quantadine, but it is a scheduled medication used as a veterinary anesthetic. But we're seeing more and more of these on the East Coast spreading to the West in 2021, 22 and 23. Currently 22 deaths, 22% of the opioid overdose deaths on the East Coast have xylazine. Lanzapam, you can see about 6,500. Clonazolam, 6,500. Clonazepam, 5,300. And Etizolam, 4,200. There were three phenylethylenes. Phenylethylamines, eutelone was almost 13,000. Amphetamines in general, 8,400. And MDMA, for ecstasy, 4,600. Two synthetic cannabinoids have popped up on the screen. We used to have Spice and K2 as the common drugs, but ABD, Butanaca, 4,700 reports. And MDMB, Orinpanaca, 3,800 reports. Those are the most common synthetic cannabinoids that are coming out. Now, these are important because some of these chemicals are used in vape delivery systems or e-cigarette systems. Lysergic acid is still around, and we should also be aware that cocaine is being imported into the United States at a higher level in 2022 and 2023 than at any span of time in the past. Now, synthetic psychoactive substances, typically called designer drugs, are derived from a variety of herbal stimulants, hallucinogens, opiates, and sedatives. Recently, Oregon has approved psilocybin as a drug of treatment for psychotic depression and other types of serious mental illness. Australia has just approved the treatment, the use of psilocybin for psychiatric disturbances. Legal highs are unregulated. They are not listed from the stands of, I should say the drugs that many of the drugs we're talking about are not reported in the pharmacy monitoring programs that many people in monitor or in chronic pain treatment are being followed with. Access and local distribution comes through mostly through the southern border, sometimes through the northern border with Canada, and frequently through the coastlines. One of the major ways of importing illegal substances into the U.S. are these semi-submarines that are just under the surface of the water coming in. And there have been many interdictions by the U.S. Coast Guard and by other national programs. This is Columbia and other nations have had high success in interdiction and in intervention for illegal transport. But gas stations, cannabis outlet stores, 44 states now have cannabis approved in some way, sex shops, and of course the internet. Now, when we look at the synthetic psychoactive substances that we're going to talk about today, so we have the cannabinomimetic, in other words, stimulating CB1 and CB2 receptor sites that were previously mentioned in the National Forensic Laboratory Information System. We have stimulants, which include the cathinones, previously called the bath salts that still exist, and they have an oxide bond on a amphetamine molecule. The piperazines, the phenylethylamines, NBOMEs, that does not mean the National Board of Osteopathic Medical Examiners, which includes amphetamines, MDMA, MDA, and eutalone. Xylazine is a newcomer to the list over the last three years. Hallucinogens, including LSD and psilocybin. Opioid and mu-receptor stimulants, kratom, which is a naturally occurring substance, has both a mu-receptor agonism and a dopamine release secondary to a stimulant, which grows naturally in the Thailand area. Interestingly enough, it's illegal in Thailand, but it is legal in the US. Isotinazine is another opioid that has hit the scene, and we'll talk about that. Crocodile, which is an old drug, which is desmomorphine, so it's a derivative of a morphine molecule, which caused significant neurovascular injury by causing vasculitis, is similar to the neurovascular changes that occur with xylazine, so we'll talk a little bit about that. Acetylfentanyl, and its multiple congeners, including fluorofentanyl, carfentanyl, and other drugs that are in the fentanyl category. The ANPP is the base structure, and only recently became illegal in China. It was legal to transport and export in the past, only recently becoming so with negotiations with China. But the vast majority of fentanyl and its precursors are coming still from China to Mexico and being transmitted through the border into the United States. Buprenorphine, just as a reminder, is still a drug that could be abused, but it is also a drug that is used to treat opioid use disorders. Phenobut, another chemical that has both stimulation and sedative effects. The vaping delivery systems, I think it's important for us to talk about that. There's been a lot of legal and illegal activity going on in that area. And the new benzodiazepines, and some being legal and some being schedule one. So benzodiazepines that were made into schedule one was just recently on July 26th, 2023. And the etizolam, gluelrazolam, clonazolam, flobrutamazolam, and diclazopam are all listed as schedule one for three years by the DEA effective July 26th, 2023. Again, some of our monitoring systems are not measuring for these types of chemicals. There is some cross reactivity with existing prescribed benzodiazepines, but the gas chromatography and the mass spectrometry and tandem mass spectrometry should be able to tease out these individual substances if they are being tested for benzodiazepines. Substances if they are being tested. Now we had during the early, the late 2000s and the early 2010s, an influx of a wide variety of synthetic CB1 and CB2 receptor agonists, which included Spice K2, the JWH formulations from, I don't know, well, it was from a US sponsored university that have, that caused significant changes. We'll talk about that in more detail. So when we talk about synthetic marijuana, we're really talking about synthetic CB1 and CB2 receptor agonists. And like the, we talked about the Butanaca and the Pinaka varieties that the NFLIS has picked up, but this has been around for quite a while. They were legal products prior to 2011. And my time in the Department of Defense overlapped with this. We had an outbreak at the Naval Academy in which 16 cadets were expelled because of synthetic cannabinoid use. And a lot of people were using these to have a cannabinoid like high without testing positive for THC. So typically these are liquids that can be sprayed on a variety of dried plant materials. The plant that was typically used was a plant called marshmallow weed, which was just a high fiber product that could be ground into very small pieces and they could spray on the CB1 or CB2 receptor agonists. But now we know that people are also using e-cigarette devices, having them essentially infused and smoked. Inhalation of the actual product is also possible too. Typically there is a CB1 or CB2 receptor agonism response. So there's a euphoria, a calming effect, and that can happen within seconds of inhalation. Intoxicating effects typically will diminish after 30 to 60 minutes, hence repeated use is common. There is a tolerance that can develop, meaning that you need to have more and more to have the same effect. And you can also have a dependence. And the whole area of THC dependence was highly debatable when we had lower grade marijuana, but now we have a product here in the Phoenix area called Shatter, which is 80% of the product is THC. These are hybridized marijuana plants with very high yield of THC. And so with that type of stimulation, we've seen things that has changed the way that we clinically address this. One, we can have people who can hallucinate with significant CB1 and CB2 receptor agonism. The second thing is that a dependence, in other words, a withdrawal syndrome, has been reported in this population. Now with the synthetic CB1 and CB2 receptor agonists, there have been a variety of other issues that have occurred and those individuals with severe mental illness, bipolar depression, schizophrenia, those individuals many times exacerbate their mental health pathology with the use of cannabinoid or CB1, CB2 receptor agonism. So the Uniform Code of Military Justice made all stimulants of CB1, CB2, exogenous CB1, CB2 receptor agonists, illegal in February, 2011. The Air Force began screening back in 2011, as did the Navy and the academies. 31% of the admissions to the drug and alcohol programs in the military, so the Army ASAP programs, the Navy programs and the Air Force programs, and everyone should be aware that all the Marines go into Navy programs. Now the Fort Belvoir and Walter Reed National Military Medical Center, Fort Belvoir is now called Alexander Facility. These are combined facilities. So we were just 20 miles north of Quantico. So a third of our members we were taking care of were from Quantico. Like I said, we had in 2011, 16 cadets from the Naval Academy expelled when they started testing for this. The old tests back in 2011 were John W. Hoffman 018, 073 and 200. And keep in mind that he developed over 60 different CB1, CB2 receptor agonists. Again, funded by the US government to find ways to stimulate the receptor without using marijuana. As it turned out, the formula got out of the Clemson University team. And then we had significant illegal manufacture of these products. Hebrew University also had a funded program to develop these. Now in 2012, in July, the Synthetic Drug Abuse Prevention Act occurred and that resulted in making all these cannabimomimetic agents schedule one. So even the two new ones that NFLIS reported, those are schedule one illegal products. And unless they're specifically exempted and unless listed in another schedule, any material compound mixture or preparation will contains any quantity of cannabimomimetic agents falls in this category now. So even when new products are made, and this has been a problem for the DEA, that they would not be able to list all the products because the industry, the drug producing industry, would always stay a step ahead by making new product which had to go through the process of being made illegal by the DEA. So we do know that they are significant and potent agonists at the CB1 receptor, also significant affinity and potency at the CB2 receptor. And I've got a couple articles documenting this. We do know that there are significant changes that occur that we normally did not see with THC, which includes hallucinations. It was unusual with the product, marijuana products, to cause hallucinations unless the person had a pre-existing psychiatric disturbance. But now we see with the newer products that there is frequently hallucinations and desired hallucinations. Now some of these products are mixed with hallucinogens such as psilocybin, LSD, PCP, things like that. Ketamine is another one that we'll touch base on a little while. So medical sequelae, hypertension, tachycardia because of the stimulation, myocardial infarctions have been reported in teenagers, nausea, vomiting, commonly seen, by the way, hyperemesis is seen with significant just THC use, hypokalemia causing muscle spasms and even seizures, acute kidney injury, seizures, coma, and increased complications with serious mental illness. In other words, a person who develops a psychiatric disturbance with early use may, and the feeling is that they most likely were headed in that direction already. We had several military members that we provided care for who became psychotic. And then you're not, if that psychosis remains for one year, that is a determination for a departure from the military because you're not deployable. Psychiatric sequelae resemble schizophrenia, hallucinogens, delusions, thought disorders, multiple reports about this. And I had one member who was with Fort Drum, the mountain unit, and in April, they were doing a bivouac. He was, he disappeared from his unit for five days. He had already been on two tours in Afghanistan and had a purple heart, he did have an IED and some PTSD issues, but no other prior problems. But in 2014, he got involved with a synthetic cannabinoid receptor agonist. And the next thing we knew is he was gone for five days. He was found naked in an area about 20 miles away by a civilian. He was brought into Fort Drum, transferred down to Fort Belvoir. He was in our warrior transition brigade for over 14 months and never did have a resolution of his psychotic disorder. So supportive care is typically used when people have these synthetic cannabinoids. Symptomatic care, dehydration being a good example, which could cause an acute kidney injury. And there's no antidotes other than treating the psychotic events with antipsychotics. Cravings, anxiety, insomnia, anorexia, including nausea and vomiting, headaches, diaphoresis, tachycardia again, all reported in the literature. Moving on to cathinones, what we used to call bath salts. These are analogs that are psychostimulant. And like I said, it essentially is an amphetamine molecule with an oxide bond on it. It is a naturally occurring product in the Middle East and in East Africa. The leaves can be chewed or they can make a cut out of them, which they put in their mouth and just sort of suck on the leaves. It's been used for centuries, if not longer. Very similar to coca leaves and coca tea. Mephedrone, methadone, MDPV were the common ones that we saw in the early 2010s. Flaca was another term for cathinones, which are synthetically generated. There's not that many cases that pop up in the NFLIS, but you need to make sure that whatever testing organization you're using tests for the typical cathinones in your area. Typically they're snorted or ingested. They're not detected by standard drug screens. They have a whole variety of nice ivory baths, soaking vanilla sky, things like that, to make it sound like they're bath salts, but these are stimulants. Fruit in the emergency room with aggressive behavior, very similar to the amphetamines. Because it's a rapid high and a rapid loss of high, it encourages repeat doses. There have been myocardial infarctions, death, all reported similar to the amphetamines and similar to cocaine. It does inhibit the reuptake of norepinephrine, dopamine, and 5-hydroxytryptophane, which means that the stimulant stays in the synapse longer. It does also stimulate presynaptic release of the monolamines, and so that's what causes that rapid onset of stimulation. Dopamine, the pleasure substance in our brain, will increase almost within 15 minutes, but the duration can last between two to seven hours. So what happens is people have the euphoria, the pleasure response. There is increased sexual arousal, like we see with amphetamines and with the cocaine. Undesired effects would be psychosis, self-mutilation, uncontrolled depression, psychotic depression, suicide attempts, and completed suicides. Because it's a stimulant, we should expect the cardiovascular system to be responsive. I had several members in the military who actually developed significant dehydration, went into myoglobinuria with acute kidney failure that had to have dialysis because of this use. Methoxylamine are all different ways to pronounce it, legal ketamine. It was illegal in February 2013, but some people still feel that since you can buy it at some of the head shops and gas stations, that it's legal. So what's interesting on this package, it says not for human consumption, must be 18 years old to buy it, and they actually show you the product which includes the oxide bond on this amphetamine type structure. So it's a white powder, it can be ingested, it can be smoked, it can be snorted. Very little is still known about its toxicity, it's not seen that often. It's similar to ketamine, and ketamine had a significant push with the ketamine clinics and the F-ketamine clinics that popped up over the past five years, but those are rapidly going away because insurance is not paying for that particular intervention right now. Rapid onset, 10 minutes, rapid offset, one to two hours, which again means people tend to use them over and over. So the desired effect is euphoria, the undesired effect is nausea, vomiting, diarrhea, paranoia, increased anxiety, and unfortunately, the cardiovascular events can be associated with a variety of cardiovascular endpoints such as myocardial infarction and things like that. Some people have an allergic type reaction to the use of this and they go into laryngospasm, pulmonary edema, as has been reported by ketamine. So NBOME, N-bombs, these are phenylethylamines, they are similar to LSD, they include the amphetamines, MDMA, MDDA, they can come as blotter paper, as you see from the DEA here, but they also can be used as powder, liquids, edibles, and now you can put them in liquid form into your set for your e-vape. Desired effect is a hallucinogenic activity, euphoria, increased sexual sensation, increased sexual longevity, and the dangers are, as with all the stimulants, psychosis, agitation, erratic behavior, suicidal ideation, seizures, cardiac events, including cardiac arrest, respiratory arrest, and death. Moving on to Kratom. Kratom is a naturally occurring product in the Thailand area. The Mitragyna species, as I said, is illegal in Thailand, which many things are illegal in Thailand. It has been used for centuries to treat opium withdrawal. Keep in mind, that's the Golden Triangle too, where a significant amount of poppy cultivation had occurred. I was doing a presentation at the old Walter Reed Army Medical Center at the conference room, and the three-star general stands up, who introduced me, and he said, I want everyone here to realize that 60% of our combat exposed military in Vietnam were either smoking or injecting heroin. And I thought, wow, that's an amazing admission by someone with that many stars on their shoulder. But it was an interesting presentation. So, currently it's unregulated in the U.S. Now, there are several states that have made, and several counties that have made Kratom illegal. So, Alabama, Arkansas, Indiana, Vermont, Rhode Island, Wisconsin, the District of Columbia, Sarasota County, Florida, have made these products illegal. However, they are legal in most of the states, and whenever the DEA has tried to stop Kratom from being available for distribution, there's been significant pushback from the nutraceutical industry, identifying that this is a product that can be used to treat opioid withdrawal. What they're not admitting, though, is that it's also a product that can be abused, because it does stimulate the mu receptor in addition to enhancing the dopamine levels in the brain. So, there's a stimulant and a suppressant in this product. So, typically you'll have that stimulation very quickly after ingestion or smoking. It does increase their alertness, elevates their energy. In high doses, there have been deaths reported from mu receptor stimulation and respiratory depression. So, the undesired effects is a respiratory depression, tolerance, and withdrawal. People do go into opioid withdrawal with all the signs and symptoms of the withdrawal process. I typically say when you're in opioid withdrawal, if you have a hole, something's coming out of it. So, you're sweating, you have large pupils, you have diarrhea, you have micturation, you have piloerection, you have muscle pain and spasms, joint discomfort. All these things go along with opioid withdrawal. We had a conference in Seattle four years ago, and when you walked out of the convention center at Seattle, this is walking out of the entrance, there's a bridge, and there was probably 50 or 60 people that were under the bridge smoking marijuana and using other products and people selling on the street, Kratom, getting their Kratom from across the street from the convention center at the Seattle Welcome Center. So, isotonitazine is a powerful synthetic opioid. It's 20 to 100 times more powerful than fentanyl, which is already our major cause of opioid overdose deaths. Now, the industry realizes that filling off your clients is not the best thing, but having things that are so strong that people go a long ways to get them. Phoenix, Arizona has drug busts almost every day. There are busts on a weekly basis of a million tablets or more. This is not an uncommon event in Phoenix. We know that the vast majority of this product is coming through at the ports of entry and coming through hidden in a variety of things. ISO has also been identified in toxicology reports in Florida, Illinois, and Wisconsin. It was first identified in 2019. Again, from an MRO standpoint, is your forensic laboratory testing for this? And if not, if you're in the area that this has become a problem, and the way to tell is to check with the DEA, because they're very good about working with the medical examiner's office and doing those screens. Now, desmomorphine, which was crocodile, crocodile, was developed in 1932 by Roche, and it's made illegally by using codeine as a derivative and using a variety of toxic household products. When it's injected, it's more potent than heroin. The Russian mafia, during the late early 2000s and the early 2010s, made buprenorphine available in Belarus, in the Ukraine, and in Chechnya. Then they shut it off, and they promoted desmomorphine. And it causes a severe vasculitis. And the way God made us is that the nerve, artery, and the vein all run together. And so what ends up happening is that you can actually cause a vasculitis so severe that you damage the nerve, and you become anesthetic in that area. So here's a person who has been using the desmomorphine. Now, this is from Providence, Rhode Island. Person just started using, and within two weeks, had a variety of phlebitic areas. This is a Russian picture showing the granulation tissue and deep ulcer secondary to desmomorphine or crocodile causing necrosis. Now, as it turned out, the drug itself was so damaging that it was not pushed by the Russian mafia later in the late 2010s. However, xylosine does a very similar amount of vasculitis. And so we're starting to see this reoccurring in Philadelphia, New York, Washington, D.C., and Atlanta. Acetylfentanyl is a Schedule I fentanyl. Fluorofentanyl and parafluorofentanyl are also Schedule I and ANPP and phenylalpha-4-ANPP are the precursors of making fentanyl. Right now, there's over 200 congeners of fentanyl. And when you're using GC-MS and MS, tandem MS, you're going to have the need to have confirmatory testing for some of these products. And again, with fluorofentanyl not being a substance that's tested very often, and yet it's the second most common fentanyl in the DEA and the NFLIS reports. Let's move on to big tobacco. And this is a concern that I have because we saw with a fentanyl epidemic a significant drop in injection drug use. Now with xylosine, we're seeing a rise in injection drug use again. Almost all of my heroin injection users when I was with the Indian Health Service stopped injecting simply by taking the pills or smoking the pills. And the distribution was ubiquitous, it was everywhere. Now what's happened is that there's been a significant effort both by the tobacco industry, which buys into the e-cigarette system, but there has been a significant rise. We know now that in 2021, 58% of adolescents in high school admit that they have used an e-cigarette. And so it's become a challenge to many people. Advertising works. And we can go back to the 1930s and 40s where camel cigarettes talked about how more doctors smoke camels. And Lucky Strikes also said that their product helped people with asthma. So it was a process in which the industry would make fictitious claims. We do know that the claim that vaping is healthier than cigarette smoking has gone into question. The product that you inhale is actually much hotter than cigarette smoke if you use a filter. So it's something that has been very challenging. Now, the people who make the e-cigarette delivery systems are saying that they can provide the same satisfaction with safe products and that they plan to switch a billion smokers away from the use of tobacco to e-cigarettes. So when we look at Juul as an example, Juul was approved in 2015 for one year before the FDA put regulatory process on that. And since then, Juul has grown dramatically. The two makers of Juul were Stanford business students and this was a product that they designed trying to say, what can we do that is gonna be good for the world and yet will make us a lot of money? They were essentially fined for the use of or for the advertisement to teenagers and the use of products that made no sense to the adult population, bubblegum flavored product, candy, cotton candy and candy cane flavors, things like that. What did happen is that there were significant pushback over the past three years. They hired a publicist from the White House. They hired Dr. Rubenstein who is the executive medical officer from UCSF that they wanted to prevent youth tobacco use. They spent only a couple of million dollars in lobbying but in Mesa, Arizona, they gave grants to the high schools talking about how kids could help their parents stop smoking tobacco by using Juul because Juul is safe. In 2023, six states have already received $346 million from Juul in regard to the advertising and the promotion to adolescents and young adults. Vape deaths are rare, only 68 reported as in the literature search I did in July of 23. It seems to be related to the product in the canister or the partridges. There are so far almost 3000 hospital admissions secondary to vape pulmonary injuries. Many teenagers are hesitant to report use because there's been so much push against the use of electronic cigarettes in adolescents. But what's interesting is that you can now get partridges in Phoenix that have cocaine, methamphetamine, a variety of opioids, including fentanyl in the vape solutions. Again, these are all illegal vape cartridges that fit into the delivery systems. Most of the youth do not know what's in the vape when they're using them. Getting back to opioid use in the military and in veterans, the leading cause of a veteran or an active duty service member to seek medical services is pain. This is one of the members I took care of at Fort Belvoir. And he has his hand reaching up out of the dirt, his best friend who died from a prescription overdose. One of our jobs at Fort Belvoir was to help people get off of ridiculous doses of oxycodone that were given by previous military providers. It was not uncommon to have people on more than 1,000. The most I ever treated was a person who was on 2,800 milligrams of oxycodone a day for severe injury. The sad thing, by the way, in regard to opioid deaths is that the VA has decreased their prescribing by more than 60%. And we have seen an increase of opioid overdose deaths in that population by over sixfold, 600% increase in opioid overdose deaths despite having their opioids curtailed or stopped and over a 700% increase in completed suicides. So, and this has also been repeated in the civilian population that people who are on long-term opioids, when they are involuntarily stopped on opioids, many times their opioid use switches over to illicit opioids or depression takes over and helplessness and hopelessness becomes part of their status. This is a list of some of the fentanyl congeners that we talked about earlier, looking at, again, almost an impossibility to test for all of those. But what I normally do when I was actively engaged in working with active substance users was to check with the DEA, what is the product I need to be worried about? Unfortunately, in Arizona, if you're on I-17, I-10 or I-8, you could have almost anything you wanted to it at the truck stops. Benabunt, it's a depressant drug. It has effects that are similar to other benzodiazepines like alprazolam or diazepam. It's also got a stimulant in there. So it has a response similar to methylphenidate or the amphetamines as an Adderall. Comes from Russia. It is not prescribed in the US, but it is sold in some supplements and you can get these online. It comes from a form of a dietary supplement and can be sold as a powder, capsule or a tablet. Xylosine is a strong sedative known as Trank. It's a veterinary tranquilizer. It's being seen now as a product mostly used with fentanyl because fentanyl has a short half-life and this adds on to the half-life. So it can expand the perceived effect of fentanyl to four to six to eight hours. Now, because of its dangers identified in clinical trials, it's only approved for veterinary use in some animals, not for humans, but that has not prevented this to become a significant factor in the exposure on the East Coast. Now, we had 1600 overdose deaths in Maricopa County in 2022. Only 18 of those members who died had xylosine detectable in their ocular fluid, their vitreous, in their right atrial blood and in their tapped bladders with a urine drug screen. And we have a state-of-the-art forensic lab in Maricopa County. So we don't feel that xylosine has come to our area yet. Fentanyl and methamphetamine is the major combined activity. It's all up to whoever's pushing it. So if the organized crime in your area has decided we're happy with this, that's what's going to be sold. It's seldom to have other product in that area by that same organized crime. Now, it was seen in 23% of the powder and 7% of the pills tested by the DEA on the East Coast. And it's now seen in over 22% of the deaths in New York, Philadelphia, Boston. Cocaine, that last line is important to read. 671 metric ton of cocaine was seized in 2022. We're talking metric ton, 1,000 kilos. So we only interdict about 10% of the influx of cocaine from Peru, Colombia and other states or other countries. So it's really important to understand that the efficiency in producing cocaine has increased dramatically. And they're not using that much in their countries of origin. It's going because of finance to Europe, Russia, Australia, Middle East, Africa, and of course the US. So a huge increase in the total amount of cocaine in the US and we're seeing a significant influx of cocaine and fentanyl replacing some of the methamphetamine. Although again, it all depends on what organized crime is pushing in your area. So what are our challenges? I really feel that vaping delivery systems have been hijacked by organized crime. They understand that number one, this was promoted very successfully in the adolescent and young adult population. The fear factor is very low about vape use and cartridges can be made to fit into any variety of e-cigarette delivery systems. And those cartridges can have anything in them. And we're seeing this happen on a fairly regular basis. More on the East Coast and West Coast than in the Southwest, but it's becoming common because of the e-cigarette acceptability rates. Cocaine is a significant challenge. The amount of cocaine coming in is astronomical. ANPP is now coming across the border and fentanyl is being cooked in the US. This did not happen until 21, 22, and 23. So typically the precursor drugs would be sent from China to Mexico, typically going to the Sonoma cartel or other cartels and their high use of highly trained super labs are producing high grade fentanyl product coming across. But now what's happened is there has been a movement of the precursor drugs coming into the US which is creating a problem. ISO being a much stronger non-fentanyl opioid B-receptor agonist should raise concern, but we're not seeing that much of it right now. It all depends on price. In order to generate heroin, it costs about $40 a gram. It can be sold for between 80 and a hundred dollars a gram. It can be cut and be sold at a higher price. To make a dose of fentanyl, which is highly variable in the pills, 20% of the tablets that are tested in Maricopa County have a fatal dose of fentanyl. But what happens is that, you know, 500 micrograms of fentanyl is a lot less than a gram of heroin. And so, and that tablet by the way is only running $4. So teenagers can buy fentanyl tablets literally with their lunch money. And unfortunately we're seeing this happen. From an osteopathic standpoint, I'm an osteopathic physician. I do believe that our concept of holistic care, looking at the entire person becomes important. I know as an MRO, many people have borne the stigma of having a substance use disorder and living in the monitored world. It's critically important that they receive the behavioral health supports necessary to maintain their recovery. Loss of recovery is a tragic loss, not only from the state monitoring systems, but also a tragic loss from the standpoint of this person's individual and family status. Pediatric and adolescent issues. I think that, you know, if you use the vaping system as an example, that product was advertised as safe, promoted to an adolescent population. Cotton candy is not really the most favorite flavor for adult pops. And you can still get cotton candy that fits into any e-delivery system at the head shops. And so this is still a big problem in regard to this. Now, when I have a grocery store a half mile from my house, it's called Fry's, it's part of the Kroger system, but I have to pass three marijuana distribution buildings to get that half mile to my grocery store. And it's had a significant impact in regard to the availability of cannabinoids, not only legally to our recreation users and our medical marijuana users in the state of Arizona, but the use of marijuana by the adolescent population has had a significant rise. Narcoterrorism is a huge problem. I mean, 350,000 people in Mexico have been murdered since, well, just in the last 17 years. And that's the ones that are known to have disappeared. But Africa is dealing with a significant problem with drug influx. Europe has still had significant challenges. Organized crime has become stronger and more evident and more ubiquitous across the world. And the impact this has to monitoring systems is also significant. We know that there's a variety of products that are out there. As an MRO, you need to know what your lab is actually testing for. And if there's other products that are of great concern, they should be monitoring that. Now, they change their system on a regular basis. Now, we do know that with GC and GC-MS and Tandem-MS that we can find and we can test for almost anything. But the reality is that without testing, this will create a challenge. So if we have some forensic labs that are not doing testing of these products or saying that this is not a problem in our area. And this was an issue for Pinal County in Arizona. They did not feel that fentanyl was a significant issue. They also were not testing for it at the medical examiner's office. And this was back in 2015. And I said, well, if we have this problem, I had just come from the DC area. I said, if we have this problem on the East Coast and they're having this problem on the West Coast and Arizona is essentially the pipeline to get fentanyl into the country, why are we not testing for it here? And they started testing in 2016, 17 and found out that yes, we have a major problem just as the rest of the country does too. So monitoring systems are gonna continue to be dynamic, which is a good thing because the industry is dynamic and we need to keep up with what's going on. I am going to go ahead and stop the presentation here. I do appreciate your participation in this program. I do not believe any of this information will be on the test exam for the MROC exam. However, this is to update you. I know the exam is going through a permutation also. So I do feel that these are important for those clinicians working with people in monitored programs and for those who are working with members who are trying to maintain the recovery. Thank you very much.

psychoactive drugs

synthetic substances

fentanyl

xylazine

cannabinoids

vaping crisis

public health

narcoterrorism

organized crime