Opiate/opioid-Related Deaths in New Hampshire. Thomas A. Andrew, MD Chief Medical Examiner State of New Hampshire

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1 Opiate/opioid-Related Deaths in New Hampshire Thomas A. Andrew, MD Chief Medical Examiner State of New Hampshire

2 A National Public Health Issue Since 2000 drug deaths increased 137% 200% increase in opioids deaths 2014: 47,055 drug deaths, representing a 1-year increase of 6.5%, from 13.8 per 100,000 in 2013 to 14.7 per 100,000 in : 28,647 opioid deaths, 61% of all drug deaths Opioid deaths increased 14% from 7.9 per 100,000 in 2013 to 9.0 per 100,000 in 2014 Heroin death rates increased by 26% from 2013 to 2014 and have more than tripled since 2010, from 1.0 per 100,000 in 2010 to 3.4 per 100,000 in 2014

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4 A National Public Health Issue States with statistically significant increases in drug death rate from 2013 to 2014: Alabama, Georgia, Illinois, Indiana, Maine, Maryland, Massachusetts, Michigan, New Hampshire, New Mexico, North Dakota, Ohio, Pennsylvania, and Virginia

5 A National Public Health Issue In 2014, the five states with the highest rates of drug overdose deaths: West Virginia (35.5 deaths per 100,000) New Mexico (27.3) New Hampshire (26.2) Kentucky (24.7) Ohio (24.6)

6 Age-Adjusted Drug Death Rate per 100,000

7 State Deaths Population Crude Rate Per 100,000 Age Adjusted Rate Per 100,000 West Virginia (54) 627 1,850, New Mexico (35) 547 2,085, New Hampshire (33) 334 1,326, Kentucky (21) 1,077 4,413, Ohio (39) 2,744 11,594, Rhode Island (44) 247 1,055, Utah (49) 603 2,942, Pennsylvania (42) 2,732 12,787, Delaware (10) , Oklahoma (40) 777 3,878, Tennessee (47) 1,269 6,549, Wyoming (56) , Massachusetts (25) 1,289 6,745, Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple Cause of Death on CDC WONDER Online Database, released 2015

8 NEW HAMPSHIRE S RANKING AMONG THE 50 STATES AND TERRITORIES According to NSDUH yr yr 26+ yr 18+ yr NSDUH NH (%) NH Rank US (%) NH (%) NH Rank US (%) NH (%) NH Rank US (%) NH (%) NH Rank US (%) 30 Day Binge 8.1% 3rd 6.7% 49.0% 3rd 38.7% 23.1% 21st 22.2% 26.6% 17th 24.6% 30 Day Marijuana 9.6% 6th 7.2% 27.7% 4th 18.9% 7.0% 13th 5.5% 9.8% 11th 7.4% Past 30 Days Illicit Drug Use 3.0% 32nd 3.4% 10.0% 1st 6.9% 2.6% 24th 2.8% 3.6% 17th 3.4% Past Year Pain Relief 4.9% 30th 5.0% 10.5% 14th 9.5% 3.2% 33rd 3.6% 4.2% 30th 4.5% Alcohol Dep. Or Abuse Past Year 4.6% 3rd 3.1% 19.2% 1st 13.7% 6.2% 24th 6.0% 7.9% 13th 7.1% Drug Dependence Only Past Year 2.3% 6th 2.0% 7.4% 1st 5.4% 1.3% 30th 1.3% 2.1% 10th 1.9%

9 NH Drug Deaths * *6 pending cases

10 Drug Deaths * by Age

11 Drug Deaths * by Sex

12 Drug Deaths * by Manner

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15 Leading Agents in NH Drug Deaths

16 NH Top Methadone Methadone Methadone Methadone Cocaine Cocaine Cocaine Oxycodone Oxycodone Oxycodone Oxycodone Cocaine Diazepam Diazepam Diazepam Heroin Heroin Fentanyl Morphine Diazepam Methadone Methadone Oxycodone Heroin Oxycodone Oxycodone Heroin Oxycodone Cocaine Cocaine Methadone Methadone Heroin Morphine Cocaine Cocaine Citalopram Fentanyl Alprazolam Morphine

17 NH Top Five * Heroin Fentanyl Fentanyl Oxycodone Heroin Heroin Cocaine Cocaine Cocaine Fentanyl Methadone Oxycodone Methadone Oxycodone Benzodiazepines

18 Single Agent Deaths (%)

19 Leading Single Agents of Death Opiates Methadone Heroin Methadone Methadone Methadone Opiates Methadone Heroin Cocaine Cocaine Cocaine Cocaine Oxycodone Oxycodone * Heroin Heroin Heroin Fentanyl Fentanyl Oxycodone Methadone Fentanyl Heroin Heroin Methadone Oxycodone/ cocaine Cocaine Methadone Methadone/ oxycodone

20 Heroin and fentanyl seen together in 39 cases in 2014 and 43 cases in 2015 to date Heroin Fentanyl

21 Fentanyl Deaths by Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec TOTAL * 2*

22 Total Fentanyl Seizures, 2014* Rank State Number of Fentanyl seizures 1 Ohio Massachusetts Pennsylvania Maryland New Jersey Kentucky Virginia Florida New Hampshire Indiana 133 *Source: CDC Health Alert Network October 26, 2015

23 *National Forensic Laboratory Information System *

24 Fentanyl Synthetic opioid 10X more potent than morphine Legitimate use: severe, chronic pain Trade names: Actiq, Duragesic, and Sublimaze Binds opiate receptors, driving up dopamine levels, producing euphoria and relaxation

25 Fentanyl Most often administered via injection, transdermal patch, or in lozenge form

26 Fentanyl Potential risk of discarded patches or improperly stored lollipops

27 Abuse Potential

28 Illicit Fentanyl Production Produced in clandestine laboratories and mixed with (or substituted for) heroin in a powder form Mixing fentanyl with street-sold heroin or cocaine markedly amplifies potency and potential dangers Street names : Apache, China girl, China white, dance fever, friend, goodfella, jackpot, murder 8, TNT, as well as Tango and Cash

29 Illicit Fentanyl Analogues Alpha-methyl Fentanyl First illicit derivative to appear on the streets Very simple modification of the fentanyl structure ~200 times as potent as morphine Acetyl Fentanyl Implicated in numerous deaths ~five times more potent than morphine CDC recommendations Increased vigilance by public health agencies, emergency departments, state laboratories, medical examiners, and coroners If fentanyl immunoassay is positive additional confirmation testing should include fentanyl and its analogs, including acetyl fentanyl 3-Methyl Fentanyl Latest derivative introduced onto the streets Up to 3000 times as potent as morphine ACETYL FENTANYL

30 Color Drug Recognition Pure white (sold as Persian White), to light tan (sold as Synthetic Heroin), to light brown (sold as Mexican Brown) Brown color comes from lactose which has been heated and has caramelized slightly Texture Street samples range from light, fine powder to coarse, cake-like, and crumbly, resembling powdered milk Odor Occasional medicinal or chemical odor, but not characteristic Packaging Sold like heroin in small zip-lock plastic bags and bindles

31 Source of Drug * RX Illicit Illicit/Rx OTC OTC/Rx OTC/Illicit Unk All Three

32 NH Drug Deaths vs. Traffic Deaths * In 2014, there were approximately one and a half times more drug overdose deaths in the United States than deaths from motor vehicle crashes

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34 We Are Not Alone Fatalities have increased in states reporting large increases in fentanyl seizures Two of the top five, Ohio and Maryland, both reported sharp increases in fentanyl-related deaths in 2014 Ohio: 92 in in 2014 Maryland: 58 in in 2014 Massachusetts currently investigating whether an abnormally sharp increase in opioid-related deaths in 2014 is attributable to fentanyl Florida recently reported 397 fentanyl fatalities in 2014, up from 185 in 2013

35 We Are Not Alone Maine*, 2015: 272 drug deaths, 31% more than in 2014 (208) Continues a multi-year rise in deaths due to heroin and illicit fentanyl, sometimes in combination with each other 20% more deaths due to illicit fentanyl and acetyl fentanyl July-Dec vs. Jan-June 5% more deaths due to heroin in same period Source: Marcella Sorg, PhD Margaret Chase Smith Policy Center, Univ. of Maine

36 More from Maine* 157/272 (58%) due either to heroin (107) and/or illicit fentanyl (74) or acetyl fentanyl (32) with a wide variety of co-intoxicant combinations with other drugs or alcohol 19 due to a combination of fentanyl and acetyl fentanyl Source: Marcella Sorg, PhD Margaret Chase Smith Policy Center, Univ. of Maine

37 More From Maine* Source: Marcella Sorg, PhD Margaret Chase Smith Policy Center, Univ. of Maine

38 Maine Source: Marcella Sorg, PhD Margaret Chase Smith Policy Center, Univ. of Maine

39 Cleveland, OH We Are Not Alone Fentanyl deaths have risen since November 2014 The drug is clandestinely manufactured (not diverted from legitimate sources) and distributed by the same networks distributing heroin 2015: projected fentanyl deaths, more than double 2014 About half with heroin, a little less than half fentanyl alone and the rest fentanyl with something else Our fentanyl overdoses tend to be a bit younger than the typical heroin overdose and we are seeing slightly more women (~1/3) with a slight majority from suburban communities" Tom Gilson, MD Chief Medical Examiner

40 Latest from Cleveland 89 fentanyl deaths in 2015 with approximately half also having heroin detected January fentanyl deaths, 7 also having heroin We had our first fentanyl pill drug seizures this month AND THEY WERE MANUFACTURED TO LOOK LIKE OXYCODONE 30mg tablets. We think this was a result of oxycodone being more expensive than fentanyl in street sales. Might also give the false sense of comfort that a pharmaceutical pill is safe.

41 Pittsburgh, PA We Are Not Alone When you hear the phrase heroin overdose, be aware that the heroin could be almost anything. 2013: 8 fentanyl related deaths, almost exclusively diverted pharmaceutical material, primarily patches January 2014: 16 deaths in Allegheny County with several additional deaths in the surrounding counties Offending heroin actually a white powder that was 1:1 heroin:fentanyl, and distributed in only two ( Bud Ice & Theraflu ) of the many different stamp bags that were out in the community New kid on the block here is acetyl fentanyl No acetyl fentanyl associated deaths in cases so far in 2015 Karl Williams, MD Chief Medical Examiner

42 We Are Not Alone Alberta, Canada Population est. 4 million 2011: 6 fentanyl-related deaths, probably related to diverted prescription medication January-June 2015:145 fentanyl-related deaths Not related to diverted prescription fentanyl, but imported and illicit preparations Sometimes fentanyl is identified in isolation, many of the cases are combined with ethanol, cocaine, methamphetamine and/or heroin Jeffery Gofton, M.D. Chief Medical Examiner

43 Naloxone The Cleveland Experience Civilian distribution started in May 2013 Since then, ~250 saves with reasonable documentation (number could be higher) 2014: law enforcement started to administer with additional saves Heroin fatalities did not decline from 2013 to 2014 (but it did not continue to rise) 2015: slight drop in mortality (195 to ~180 deaths) but still substantially higher than a decade ago I see the bottom line as that the program is actually very successful but the problem is (for the time being) bigger than the solution.

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46 Economic Cost $1.84 Billion/year 2.8% GSP 10,000 people out of the workforce Cost to state and businesses Absenteeism Unfilled positions Public Safety Healthcare

47 Guidance that Drives Solutions

48 Treatment:

49 Medication-Assisted Treatment

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51 1 Death 9 in Rehab 2, ED visits 11, addicted 52, recreational users 150,286

52 Acknowledgment Tym Rourke, MA Director, Substance Use Grantmaking Chair Governor s Commission on Alcohol and Drug Abuse Prevention, Treatment and Recovery