Leveraging data to monitor the rise of cocaine and methamphetamine in Philadelphia

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2 Leveraging data to monitor the rise of cocaine and methamphetamine in Philadelphia Lia N. Pizzicato, MPH Substance Use Epidemiologist Philadelphia Department of Public Health

3 Learning Objectives Explain unique data systems that can be leveraged to monitor cocaine and methamphetamine trends Describe the epidemiology of overdose deaths involving cocaine and methamphetamine Identify how drug seizure data informs drug mixing patterns

4 Agenda 1 State of the Crisis in Philadelphia 2 Cocaine Trends 3 Crack Cocaine Outbreak 4 Methamphetamine Trends 5 Survey of Individuals who Use Drugs 6 Conclusions

5 State of the Crisis

6 Philadelphia had the highest overdose death rate in counties associated with the top 10 largest U.S. cities in 2016 Philadelphia Cook (Chicago) Maricopa (Phoenix) NYC (5 Counties) Dallas San Diego Harris (Houston) Bexar (San Antonio) Los Angeles Santa Clara (San Jose) Overdose Rate per 100,000 Residents CDC WONDER, 2016

7 Drug overdoses caused 4x as many deaths as homicides in 2017 Peak AIDS Deaths (935)

8 < Female Male White Black Hispanic Other Number of Deaths All geographic regions and demographic groups are affected Demographics of Overdose Deaths Age Group Gender Race/Ethnicity

9 Unintentional drug deaths (N) 1,217 people died from drug overdoses in Non-opioid related Opioid related 0 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q Source: Philadelphia Department of Public Health

10 Cocaine Trends

11 Percentage of Total Deaths Involving Cocaine The percentage of total deaths involving cocaine has remained constant 100% 90% 80% 70% 60% 50% 47% 48% 51% 46% 44% 43% 45% 49% 40% 30% 20% 10% 0% Source: Philadelphia Department of Public Health

12 Percentage of Total Deaths Involving Cocaine without Opioids The percentage of overdose deaths involving cocaine and no opioids has remained constant 18% 16% 14% 12% 16% 14% 13% 14% 15% 12% 13% 10% 9% 8% 6% 4% 2% 0% Source: Philadelphia Department of Public Health

13 Percentage of Total Deaths Involving Cocaine and Fentanyl Overdose deaths involving cocaine and fentanyl have increased dramatically 35% 32% 30% 25% 20% 18% 15% 10% 5% 0% 10% 4% 5% 1% 1% 2% Source: Philadelphia Department of Public Health

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15 We sought to determine if the increasing number of cocaine and fentanyl deaths is a results of: a) Substitution of fentanyl for heroin (with or without user knowledge) among individuals that engage in speedballing? b) The cocaine supply being tainted with fentanyl?

16 Methods Examined 2017 fatal overdose deaths Compared cocaine and fentanyl (without additional opioids) deaths to: Cocaine only (without other opioids) Cocaine & heroin (with or without fentanyl) Examined demographics and evidence of injection Examined DEA drug seizure data

17 Age Category p< % 90% 13% 14% 80% 70% 53% 60% 50% 40% 30% 20% 10% 0% 38% 8% Cocaine only 57% 52% 30% 33% Cocaine & Fentanyl Cocaine & Heroin (± Fentanyl) 55+ years years years Source: Philadelphia Department of Public Health

18 Sex 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 65% 35% 75% 76% 25% 24% Cocaine only Cocaine & Fentanyl Cocaine & Heroin (± Fentanyl) Male Female Source: Philadelphia Department of Public Health

19 Race/Ethnicity 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 5% 71% 23% p< % 26% 53% 16% 22% 62% Cocaine only Cocaine & Fentanyl Cocaine & Heroin (± Fentanyl) Other Hispanic Black White Source: Philadelphia Department of Public Health

20 Evidence of Injection p< % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 7% 94% 46% 50% 54% 50% Cocaine only Cocaine & Fentanyl Cocaine & Heroin (± Fentanyl) Yes No Source: Philadelphia Department of Public Health

21 Percentage of Cocaine Seizures Cocaine seizures involving heroin or fentanyl have remained low 1.6% 1.4% 1.2% 1.0% 0.8% 0.6% 0.4% 0.2% 0.0% Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q Percentage Containing Heroin Percentage Containing Fentanyl Source: DEA National Forensic Laboratory Information System

22 Summary Toxicology data in combination with drug seizure data suggests that increase in deaths likely driven by individuals that use opioids (i.e. cocaine and fentanyl are being mixed for purposes of speedballing) But not always...

23 Crack Cocaine Overdose Outbreak & Rapid Response

24 Background on Rapid Response Final recommendations May 19, 2017 Establish use of real-time data to support a rapid response plan

25 Leverage Syndromic Surveillance Real-time surveillance through HMS Epicenter Chief complaints from hospital emergency departments Syndromes Created: Drug Overdose Opioid Generates alerts when counts are above what is expected based on historical trends

26 5/15/2018 5/16/2018 5/17/2018 5/18/2018 5/19/2018 5/20/2018 5/21/2018 5/22/2018 5/23/2018 5/24/2018 5/25/2018 5/26/2018 5/27/2018 5/28/2018 5/29/2018 5/30/2018 5/31/2018 6/1/2018 6/2/2018 6/3/2018 6/4/2018 6/5/2018 6/6/2018 6/7/2018 6/8/2018 6/9/2018 6/10/2018 6/11/2018 6/12/2018 6/13/2018 6/14/2018 6/15/2018 6/16/2018 6/17/2018 6/18/ Surge Detected on June 18, 2018 at Local Hospital Count Exponential Moving Average Threshold Exponential Moving Average Predicted Value Source: DEA ARCOS

27 Outbreak Details In total 18 patients presented with a life threatening poisoning Many (N=17) responded to naloxone and required higher doses Patients and witnesses reported smoking crack cocaine but were founds unresponsive with symptoms aligning to opioid toxicity (i.e. lethargy, pinpoint pupils, and respiratory depression) Patients were opioid naïve Most had never presented to the health system previously

28 Outbreak Details Median age was 53 years and 67% of individuals were male Majority of patients were from the same ZIP code suggesting point source adulteration In total, 3 of the 18 people died Medical complications occurred in additional patients (i.e. acute kidney injury, anoxic brain injury, rhabdomyolysis) Urine testing completed for 16/18 patients 100% positive for cocaine 94% positive for fentanyl

29 Response Health Alert Released by Health Department Media Disseminated Warnings Health Department Engaged Neighborhoods affected

30 Source: Philadelphia Inquirer

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34 Methamphetamine Trends

35 Grams sold Stimulant sales have also increased dramatically in Philadelphia Methylphenidate (Ritalin) Amphetamine (Adderall) Lisdexamfetamine (Vyvanse) Source: DEA ARCOS

36 Number of Methamphetamine Involved Overdose Deaths Methamphetamine involved overdose deaths are increasing in Philadelphia

37 Percentage of Methamphetamine Deaths Containing Fentanyl Methamphetamine deaths containing fentanyl have increased 100% 90% 80% 86% 70% 60% 59% 50% 40% 30% 20% 10% 0% 26% 19% 8% 0% 0% 0%

38 Results from a Survey of People who Use Drugs

39 Results from a recent survey of people who use drugs Administered in Kensington neighborhood 225 individuals surveyed Offered $5 gift card incentive Source: Philadelphia Department of Public Health

40 Unknown Female Male White Black Hispanic Other No Yes Survey respondents were demographically diverse 80% 72% 70% 60% 50% 60% 50% 49% 40% 30% 20% 37% 29% 17% 28% 17% 22% 10% 0% 7% 8% 1% 0% 1% Age Categories Gender Race/Ethnicity Living on Street Source: Philadelphia Department of Public Health

41 Percentage of total Survey Respondents Most individuals indicated recent use of opioids and stimulants 60% 50% 55% 40% 30% 27% 20% 10% 0% Opioids & Stimulants* Opioids Only Stimulants Only 5% *Does not indicate combination use Source: Philadelphia Department of Public Health

42 Percentage of Using Stimulant Type There is a mix in the type of stimulants used for both opioid and non-opioid users 60% 50% 49% 56% 40% 30% 26% 29% 20% 10% 11% 8% 0% Non-Opioid Users Opioid Users Powder Cocaine Crack Cocaine Methamphetamine Source: Philadelphia Department of Public Health

43 Percentage Using Stimulants More people living on the street use stimulants 80% 70% 69% 60% 50% 40% 43% 30% 20% 10% 0% Not Living on the Street Living on the Street Source: Philadelphia Department of Public Health

44 Percentage Using Stimulant Type Type of stimulant use is varied between shelter and street based stimulant users 70% 60% 59% 50% 47% 40% 30% 31% 33% 32% 20% 10% 0% 13% Not Living on the Street Living on the Street Powder Cocaine Crack Cocaine Methamphetamine Source: Philadelphia Department of Public Health

45 Conclusions

46 Conclusions Stimulant use is on the rise in Philadelphia Much of recent stimulant related mortality is associated with co-use with fentanyl The Department of Public Health is using various data sources to monitor stimulants including: Mortality data from the Philadelphia Medical Examiner DEA ARCOS DEA National Forensic Laboratory Information System Hospital Emergency Department Syndromic Surveillance Surveys among people who use drugs Expanding Educational Resources for Other Drugs

47 For more information: Lia N. Pizzicato, MPH Substance Use Epidemiologist Philadelphia Department of Public Health