Drug Overdose Deaths St. Louis County, Missouri

Transcription

1 Drug Overdose Deaths St. Louis County, Missouri An overdose occurs when an excess and dangerous amount of a substance, such as alcohol, over thecounter medicine, prescription drugs, or illicit drug is consumed intentionally or unintentionally. Drug overdose is the number one cause of injury related death in the United States. 1 Across the nation, the drug overdose death rate has seen a significant increase from 12.3 per 100,000 population in 2010 to 19.8 in 2016, a 61% increase. 2 The increase in overdose death rate is even larger in St. Louis County. Specifically, the drug overdose death rate increased by 79% from 2010 to Over the seven years for which the most recent data is available, the United States, Missouri and St. Louis County experienced their highest overdose death rates in 2016, 19.8 per 100,000 population, 23.6 per 100,000 population, and 28.4 per 100,000 population, respectively (Figure 1). Using data from the Missouri Department of Health and Senior Services, Bureau of Vital Statistics, this report provides a description of trends and demographic characteristics of St. Louis County, Missouri residents for drug overdoses and a more detailed look at drug overdoses involving different types of opioids from 2010 through This report is divided into two sections: All Drug Overdoses, which contains cocaine, opioids, benzodiazepines, psychostimulants, unspecified narcotics, and unspecified drugs. Overdoses Involving Opioids: o Natural and Semi Synthetic Opioids, excluding Methadone (prescription opioids), o Methadone, o Heroin, and o Synthetic Opioids such as Fentanyl. Figure 1. Age adjusted rates for drug overdose deaths, United States, Missouri, and St. Louis County, MO, DEATHS PER 100,000 POPULATION YEAR United States Missouri St. Louis County Source: Centers for Disease Control and Prevention, National Center for Health Statistics.

2 Drug overdose deaths Page 2 of 33 Drug overdoses involving any type of drug affect approximately 184 individuals per year in St. Louis County (Table 1). Residents aged had the highest rate of overdose than any age group, 40.3 per 100,000. Males died at disproportionately higher rate from an overdose compared to females. Black/African American and White residents did not experience death rates significantly different from each other. Those living in high and very high neighborhood poverty areas experienced the highest overdose rates, registering average overdose rates over 28 per 100,000 from 2012 to Overdose rates are highest in the Inner North and South regions compared to the Central, Outer North, and West regions of the county. Residents aged 25 to 44 had the highest overdose death rate involving any drug from 2010 to Crucially, this age group saw almost a 90% increase in overdose deaths from 32.7 in 2012 to 61.9 per 100,000 in 2016 (Figure 2; Appendix 1). Those < 18 years and 65 years and over had the lowest average 5 year rates from 2012 to 2016 at 1.3 per 100,000 and 3.6 per 100,000, respectively. Figure 2. Age specific rates for drug overdose deaths, St. Louis County, MO, DEATHS PER 100,000 POPULATION YEAR < and over Source: Missouri Department of Health and Senior Serices, Bureau of Vital Statistics..

3 Drug overdose deaths Page 3 of 33 Table 1. Drug overdose deaths per 100,000 population, St. Louis County, Rate 95% Confidence Count per year St. Louis County to Age Group < 18 years to years to years to years to years and over to Sex Male to Female to Race/Ethnicity Asian 1.0* 0.1 to Black/African American to Hispanic or Latino 6.3* 2.2 to Multiple to White to Neighborhood Poverty Very High to High to Medium to Low to Geographic Area Central to Inner North to Outer North to South to West to Comparisons: Higher than St. Louis County rate Lower than St. Louis County rate Notes: Source: Missouri Department of Health and Senior Services (MoDHSS), Bureau of Vital Statistics. Case Definition: International Classification of Diseases, Tenth Revision (ICD 10) underlying cause poisoning codes X40 X44 (unintentional), X60 X64 (suicide), X85 (homicide), or Y10 Y14 (undetermined intent). Rates are age adjusted to the 2000 US population (not including Age Group rates). *Too few cases to meet precision standard (relative standard error <30%); interpret with caution.

4 Drug overdose deaths Page 4 of 33 The Inner North region of St. Louis County has seen the largest increase in overdose deaths over the 7 year period from 2010 to 2016 (Figure 3; Appendix 1). Since 2010, the overdose death rate in the Inner North region has nearly doubled, with the sharpest increase observed from 2015 to With exception of the Central region, where an apparent leveling off of overdose death rate was observed, all regions of St. Louis County have recorded a very sharp increase in overdose deaths in Of note, the West region of St. Louis County, which previously had the lowest overdose rates consistently relative to other parts of the county, had a slightly higher rate than Central and Outer North regions of the county in Figure 3. Age adjusted rates for drug overdose deaths by region, St. Louis County, MO, DEATHS PER 100,000 POPULATION YEAR Outer North Inner North Central South West Source: Missouri Department of Health and Senior Serices, Bureau of Vital Statistics.. Drug overdoses involving synthetic opioids, such as fentanyl and tramadol, in 2016 had almost tripled since 2010 (Figure 4; Appendix 2). Deaths from drug overdoses involving synthetic opioids excluding methadone have increased from just 8% in 2010 to 51% in Although overdose deaths involving natural and semi synthetic opioids, such as codeine and morphine, almost doubled from 13% in 2010 to 22% in 2015, the proportion of deaths due to these drugs decreased to 14% in This is consistent with the national statistics, which saw a 5% decreases in the same time frame. 2 The majority of overdose deaths involved heroin in 2010 (49%) and 2015 (53%). However, this was no longer the case in 2016, as synthetic opioids excluding methadone became the leading cause of overdose deaths.

5 Drug overdose deaths Page 5 of 33 Deaths involving methadone have dropped gradually since 2010, registering a 4% decline between 2010 and Drug overdoses involving benzodiazepines increased from 4% in 2010 to 7% in 2015, but declined to 4% in Overdoses due to psychostimulants, which includes methamphetamines, saw a 5% increase from 2010 to 2016 in St. Louis County. This is similar to the national trend, which saw a 6% increase during the 6 year period from 2010 to Overdoses due to unspecified drugs have decrease by almost 50% since This may be attributed to the primary drug seen in overdoses being an opioid as well as improved toxicology methods at the local medical examiner s office. Figure 4. Percentage of drug overdose deaths involving select drug categories, St. Louis County, MO, 2010, 2015, and Natural and semisynthetic opioids Methadone Heroin Drug Category Synthetic Opioids excluding methadone Cocaine Unspecified Narcotics Benzodiazepines Psychostimulants with abuse potential Unspecified Drugs Percent Source: Missouri Department of Health and Senior Services, Bureau of Vital Statistics.

6 Drug overdose deaths Page 6 of 33 Drug overdose deaths involving opioids Drug overdoses involving opioids accounted for 66.4% of the 63,632 drug overdose deaths in the United States in The age adjusted rate nationally changed from 10.4 per 100,000 in 2015 to 13.3 in 2016, a 28% increase. From 2015 to 2016, deaths involving natural and semi synthetic opioids increased by 12.8%. In the Midwest Census region, natural and semi synthetic opioids increased 3% from 3.3 to 3.4 per 100,000 while St. Louis County increased by 14% from 3.5 in 2015 to 4.0 per 100,000 in From 2015 to 2016, Missouri as a whole recorded a staggering 151% increase in death rate from natural and semi synthetic opioids. Methadone deaths in the United States declined by 9.1% from 2014 to 2015 and the rate remained unchanged in 2016; similarly, no change was observed in the Midwest Census region. Deaths involving heroin and other synthetic opioids not including methadone, such as fentanyl, have seen a significant increase in recent years. From 2015 to 2016 alone, the overdose rate increased by 19.5% and 100% for heroin and synthetic opioids not including methadone, respectively. In the Midwest Census region, deaths involving heroin have increased by 17.3% and those involving synthetic opioids have increased by 95% from 2014 to Both Missouri and St. Louis County have seen a reduction in heroin deaths and increases in synthetic opioid deaths. Although St. Louis County experienced higher reduction levels than Missouri for heroin, 25% versus 8.6% from 2014 to 2015, a 36% increase was observed in Of note, an even greater increase in death of 295% was recorded in overdose deaths due to synthetic opioid from 2015 to In St. Louis County, overdoses involving opioids accounted for the majority of overdose deaths from 2012 to 2016 (Table 2). St. Louis County averaged 125 deaths involving opioids each year, accounting for approximately 70% of all overdose deaths. Nearly two times the number of people aged years old died from an overdose involving opioids compared to people aged or years. Males were 3 times more likely to die from an opioid involved overdose than females. There was no difference between Black/African American and White death rates; however, Black/African Americans had a higher burden of overdose deaths involving opioids than their White counterparts. High neighborhood poverty areas had significantly higher rates than the overall St. Louis County rate, 19.2 per 100,000 versus 13.6 per 100,000 population. However, this rate was not statistically different from the other neighborhood poverty areas. Over the 5 year period from 2012 to 2016, the Inner North region registered the highest rate of overdose deaths involving opioids, at 20.7 per 100,000 population.

7 Drug overdose deaths Page 7 of 33 Table 2. Drug overdose deaths involving opioids, per 100,000 population, St. Louis County, Rate 95% Confidence Count per St. Louis County to Age Group < 18 years to years to years to years to years and over to Sex Male to Female to Race/Ethnicity Black/African American to Hispanic or Latino 2.3* 0.3 to Multiple 5.3* 1.3 to White to Neighborhood Poverty Very High to High to Medium to Low to Geographic Area Central to Inner North to Outer North to South to West to Comparisons: Higher than St. Louis County rate Lower than St. Louis County rate Notes: Source: Missouri Department of Health and Senior Services (MoDHSS), Bureau of Vital Statistics. Case Definition: International Classification of Diseases, Tenth Revision (ICD 10) underlying cause poisoning codes X40 X44 (unintentional), X60 X64 (suicide), X85 (homicide), or Y10 Y14 (undetermined intent) and multiple cause codes T40.0, T40.1, T40.2, T40.3, or T40.4. Rates are age adjusted to the 2000 US population (not including Age Group rates). *Too few cases to meet precision standard (relative standard error <30%); interpret with caution.

8 Drug overdose deaths Page 8 of 33 Drug overdoses involving opioids have affected residents aged the most over the 6 year period from 2010 to 2016 (Figure 5). All three age groups, 18 24, 25 44, and have seen increases in deaths since Individuals years old experienced higher death rates than any other age group even after a 19% decrease in the rate of overdose deaths involving opioids occurred from 2014 to Since 2010, overdoses involving opioids have increased 140% for year olds from 12.7 to 30.5 per 100,000 in A 43% increase in the rate of deaths for year olds occurred from 2010 to 2016, 8.8 to 12.6 per 100,000. Figure 5. Drug overdoses involving opioids age specific rates for select age groups, per 100,000 population, St. Louis County, MO, Rate per 100,000 population Data Source: Missouri Department of Health and Senior Services, Bureau of Vital Statistics Both males and females have seen an increase in overdoses involving opioids since 2010 (Figure 6). Females have seen a 55% increase in deaths from 2010 to 2016, 5.5 to 8.5 per 100,000. The death rate for males from 2010 to 2016 nearly doubled, 15.4 to 28 per 100,000, representing an average of 14% increase each year. In 2016, males died from overdoses involving opioids at a rate over three times that of female residents of St. Louis County. Figure 6. Drug overdoses involving opioids age adjusted rates by sex, per 100,000 population, St. Louis County, Rate per 100,000 population Male Female Data Source: Missouri Department of Health and Senior Services, Bureau of Vital statistics. Note: Error bars ( I ) represent the 95% confidence interval.

9 Drug overdose deaths Page 9 of 33 Since 2010, there have been remarkable disparities by geographic subregions in death rates due to overdoses involving opioids year over year (Figure 7). Overall, the Inner North region continues to register the highest rates of overdose deaths involving opioids and has seen a two fold increase in death rates between 2010 and Similarly, the Outer North region saw almost doubling of its overdose rate up from 6.6 per 100,000 in 2010 to 12.7 per 100,000 in This region s rate peaked in 2013 and decreased by 38.9% from 12.6 per 100,000 during its peak year to 7.7 per 100,000 in 2015 and went up again in The Central region saw a 124% increase in overdoses involving opioids since 2010, up from 5.4 to 12.1 per 100,000 in Unlike the Outer and Inner North regions, this increase has been more consistent over the 7 year time period. Although the South region recorded an increase of about 37% in overdose death rates from 2010 to 2016, it has experienced the largest rate fluctuations: 21.5 per 100,000 in 2011 to its lowest of 10.4 in 2012 and back up to 18.3 in 2014, then down to 11 per 100,000 in 2015, and back up to 20.1 per 100,000 in 2016 The West region of the County saw similar fluctuations, recording relatively low rates from 2011 to 2013, then going up in 2014 and back down again in 2015, and finally recording it highest rate in Figure 7. Drug overdoses involving opioids age adjusted rates by region, per 100,000 population, St. Louis County, Rate per 100,000 population Outer North Inner North Central South West Data Source: Missouri Department of Health and Senior Services, Bureau of Vital Statistics.

10 Drug overdose deaths Page 10 of 33 Opioid overdose rates are highest in the northern and southern areas of Saint Louis County, particularly along two interstate systems, I 70 and I 55. Although the West and central regions do not have comparatively high rates, there are still many deaths occurring among residents in this region (Map 1). Map 1. Age adjusted drug overdoses involving opioids death rates per 100,000, St. Louis County,

11 Drug overdose deaths Page 11 of 33 Drug overdose deaths involving natural and semi synthetic opioids Natural and semi synthetic opioids are composed of prescription opioids. Natural opioids and opiates include the likes of morphine and codeine. Morphine is a natural opioid derived from the plant opium and used for pain treatment. 3 Most of morphine in the United States is processed into codeine and other similar drugs while a small amount of morphine is used for pharmaceutical products. Chronic use of morphine results in tolerance and dependence, both physically and psychologically. A common semisynthetic is oxycodone and is synthesized from parts of the poppy plant. This is a prescription drug most commonly known as OxyContin. Overdose deaths from natural and semi synthetic opioids are presented in Table 3 and Appendix 3. From 2012 to 2016, the overdose rate involving natural and semi synthetic opioids more than doubled from 1.8 per 100,000 to 4.0 per 100, The highest rates occurred among those aged years. The overdose death rate in this age group nearly tripled from 3.3 per 100,000 in 2012 to 8.6 per 100,000 in From 2012 to 2016, male overdose rate was approximately 2 times the female overdose rate, 4.1 versus 2.4 per 100,000 population. White residents in St. Louis County made up the majority of overdose deaths involving natural and semi synthetic opioids. Even though low neighborhood poverty areas had higher counts, high neighborhood poverty areas had rates almost double those of low neighborhood poverty areas.

12 Drug overdose deaths Page 12 of 33 Table 3. Drug overdose deaths involving natural and semisynthetic opioids, including codeine and morphine, per 100,000 population, St. Louis County, Rate 95% Confidence Count per St. Louis County to Age Group < 18 years 0.4* 0.1 to years to years to years to years and over to Sex Male to Female to Race/Ethnicity Black/African American to Hispanic or Latino 1.0* 0.0 to Multiple to White to Neighborhood Poverty Very High 1.9* 0.5 to High to Medium to Low to Geographic Area Central to Inner North to Outer North to South to West to Comparisons: Higher than St. Louis County rate Lower than St. Louis County rate Notes: Source: Missouri Department of Health and Senior Services (MoDHSS), Bureau of Vital Statistics. Case Definition: International Classification of Diseases, Tenth Revision (ICD 10) underlying cause poisoning codes X40 X44 (unintentional), X60 X64 (suicide), X85 (homicide), or Y10 Y14 (undetermined intent) and multiple cause code T40.2. Rates are age adjusted to the 2000 US population (not including Age Group rates). *Too few cases to meet precision standard (relative standard error <30%); interpret with caution.

13 Drug overdose deaths Page 13 of 33 Drug overdose deaths involving heroin Heroin is processed from morphine and is a rapid acting opioid. 3 Heroin can be found in a few forms such as white powder and black tar. The most significant effect of heroin use is addiction with tolerance occurring over time, resulting in an increase in dose. Many users do not know the strength of the heroin they are using or the contents. The Midwest Census Region had the second highest rate of overdose involving heroin in 2015, 6.1 per 100,000 population, slightly behind the Northeast Census Region, which had a rate of 6.3 per 100,000. Both regions had significantly higher rates than the South and West Census Regions. However, all regions have seen an increase in heroin involved overdose deaths. 4 Figure 8 shows overdoses involving heroin death rates for St. Louis County, the Midwest Census Region, and the United States from 2010 through Although a modest decline was observed in overdose deaths involving heroin in St. Louis County in 2015, the overdose death rate went up again in 2016, reaching the highest level since In 2016 the St. Louis County overdose rate was over 2.5 times the national average 12.4 per 100,000 population as compared to 4.9 per 100,000 for the United States. Similarly, St. Louis County experiences overdose deaths involving heroin at a rate 1.5 times higher than the Midwest Census Region in 2015; it is important to note that this is one of the regions most affected by this epidemic in the country. Although there has been some fluctuation in overdose deaths involving heroin in St. Louis County, overdose deaths have consistently been trending up since 2010 across the United States. Figure 8. Age adjusted rates for drug poisoning deaths involving heroin: St. Louis County, Midwest, and United States, Deaths per 100,000 Population St. Louis County Midwest Census Region United States Sources: Missouri Department of Health and Senior Services, Bureau of Vital Statistics and the Centers for Disease Control and Prevention, National Center for Health Statistics. Note: Error bars ( I ) represent the 95% confidence interval.

14 Drug overdose deaths Page 14 of 33 From 2010 to 2016, in St. Louis County, men were consistently more likely to die of overdose deaths involving heroin than women (Figure 10). Between 2010 and 2016 St. Louis County men died at a rate 3.3 to 4.2 times that of female residents. With exception of a modest decline recorded in 2012 for females and 2015 for males, the trend of overdose death rates have been trending up in St. Louis County since The widest gap between females and males in overdose death rate was recorded in 2014, when male residents died of overdoses involving heroin, at a rate approximately 4.2 times that of females. Figure 10. Age adjusted rates for drug poisoning deaths involving heroin by gender, St. Louis County, Deaths per 100,000 population Male Female Source: Missouri Department of Health and Senior Services, Bureau of Vital Statistics. Note: Error bars ( I ) represent the 95% confidence interval. From 2012 to 2016 all regions of the county recorded increases in overdose deaths involving heroin (Figure 11). Of note, three St. Louis County regions (Central, Outer North, and South) recorded slight declines in overdose death rates in The West region, which had the lowest rates in 2012 and 2014, compared to the other geographic subregions, had the third highest rate in In 2012, 2014, and 2016 the Inner North and South regions of St. Louis County had the highest overdose death rates compared to the other subregions of the county. Figure 11. Age adjusted rates for drug poisoning deaths involving heroin by geographic area, St. Louis County, 2012, 2014, and Deaths per 100, Central Inner North Outer North South West Source: Missouri Department of Health and Senior Services, Bureau of Vital Statistics. Note: Error bars ( I ) represent the 95% confidence interval.

15 Drug overdose deaths Page 15 of 33 St. Louis County had approximately 93 overdose deaths involving heroin from 2012 to 2016 (Table 4). The 5 year rate from 2012 to 2016 was 10.3 per 100,000 population. Rates were highest for individuals that were aged 25 to 44, male, living in areas of high poverty, and the Inner North region of the county. The lowest rates geographically occurred in the Central and West regions of the county. Males were 3.6 times more likely to die from an overdose involving heroin than females. The 5 year rate showed no statistical difference between Black/African Americans and Whites. Table 4. Drug overdose deaths involving heroin per 100,000 population, St. Louis County, Rate 95% Confidence Count per St. Louis County to Age Group < 18 years 0.6* 0.3 to years to years to years to years and over 0.5* 0.1 to Sex Male to Female to Race/Ethnicity Black/African American to Hispanic or Latino 1.5* 0.2 to Multiple 3.3* 0.9 to White to Neighborhood Poverty Very High to High to Medium to Low to Geographic Area Central to Inner North to Outer North to South to West to Comparisons: Higher than St. Louis County rate Lower than St. Louis County rate Notes: Source: Missouri Department of Health and Senior Services (MoDHSS), Bureau of Vital Statistics. Case Definition: International Classification of Diseases, Tenth Revision (ICD 10) underlying cause poisoning codes X40 X44 (unintentional), X60 X64 (suicide), X85 (homicide), or Y10 Y14 (undetermined intent) and multiple cause code T40.1. Rates are age adjusted to the 2000 US population (not including Age Group rates). *Too few cases to meet precision standard (relative standard error <30%); interpret with caution.

16 Drug overdose deaths Page 16 of 33 Drug overdose deaths involving synthetic opioids Synthetic opioids are synthesized in laboratories, typically outside of the United States, and act on the same areas of the brain as natural opioids. 3 Examples of synthetic opioids are fentanyl, tramadol, and hydromorphone. In 2013, a re emergence of trafficking and abuse of synthetic opioids occurred, including fentanyl and its analogs such as acetyl fentanyl, furanyl fentanyl, and U Fentanyl is about 100 times more potent than morphine (a natural opioid) and 50 times more potent than heroin, making its use more likely to result in death. Hydromorphone is available as a prescription and is 2 8 times more potent than morphine and is rapid onset. St. Louis County has experienced an increase in overdoses involving synthetic opioids while the proportion of overdoses involving heroin have decreased in recent years. Since 2010, the overdose deaths involving synthetic opioids in St. Louis County has increased significantly (Table 5; Appendix 3). From 2012 to 2016, the average death rate due to overdoses involving synthetic opioids in St. Louis County was 3.9 per 100,000 population. The 2016 rate was over 49 times that of 2012, 14.6 per 100,000 versus 0.3 per 100,000 population; this represents a staggering 4200% increase in the number of deaths due to synthetic opioids. The 2012 to 2016 overdose rate for year old residents was significantly higher than the overall county rate. Similarly, just looking at 2016, the overdose rate involving synthetic opioids was approximately 2.3 times higher: 14.6 per 100,000 for the entire county compared to 33.2 per 100,000 for this age group. The majority of deaths for year olds began in The age specific rate in 2016 was 20.3 per 100,000 population. Both males and females have seen increases in deaths involving synthetic opioids from 2012 to Specifically, the death rates due to synthetics in 2016 was 1.9 times that of 2012 for females and 1.3 times for males. The Inner North region had the largest increase in deaths involving synthetics, averaging 13 deaths per year with an average rate of 7.5 per 100,000 population. Although the Inner North had the highest rate for overdoses involving synthetics, Central and South regions have seen a significant increase in deaths from 2014 to 2016, 0.7 to 8.1 per 100,000 (Central region) and 1.7 to 17.6 per 100,000 (South region).

17 Drug overdose deaths Page 17 of 33 Table 5. Drug overdose deaths involving synthetic opioids, per 100,000 population, St. Louis County, average Rate 95% Confidence Count per St. Louis County to Age Group < 18 years to years to years to years to years and over to Sex Male to Female to Race/Ethnicity Black/African American to Hispanic or Latino 1.7* 0.1 to Multiple to White to Neighborhood Poverty Very High to High to Medium to Low to Geographic Area Central to Inner North to Outer North to South to West to Comparisons: Higher than St. Louis County rate Lower than St. Louis County rate Notes: Source: Missouri Department of Health and Senior Services (MoDHSS), Bureau of Vital Statistics. Case Definition: International Classification of Diseases, Tenth Revision (ICD 10) underlying cause poisoning codes X40 X44 (unintentional), X60 X64 (suicide), X85 (homicide), or Y10 Y14 (undetermined intent) and multiple cause code T40.4. Rates are age adjusted to the 2000 US population (not including Age Group rates). *Too few cases to meet precision standard (relative standard error <30%); interpret with caution.

18 Drug overdose deaths Page 18 of 33 The highest rates of overdose deaths involving heroin and synthetic opioids were clustered along Route 67 and Interstate 70 in the northern portion of the county as well as an area near I 55 in the southern part of the county (Map 2). This pattern is very similar to that depicted in Map 1, which is expected since the majority of opioid deaths are illicit heroin and synthetic opioids. Map 2. Age adjusted drug overdoses involving heroin and synthetic opioids death rate per 100,000 population, St. Louis County,

19 Drug overdose deaths Page 19 of 33 Methods Data was obtained from the Missouri Department of Health and Senior Services, Bureau of Vital Statistics for the years 2010 to Using Recommended CSTE Surveillance Indicators for Substance Abuse and Mental Health, cases of drug overdoses were identified using the International Classification of Diseases, Tenth Revision (ICD 10) underlying cause poisoning codes X40 X44 (unintentional), X60 X64 (suicide), X85 (homicide), or Y10 Y14 (undetermined intent) and multiple cause codes T40.0 T40.9, T42.4, T43.6, and T50.9. The data received captures all overdose deaths of St. Louis County residents (within or outside of St. Louis County). The American Community Survey (ACS) was used to generate 1 year estimates for the St. Louis County population by age, gender, and race for The percent of residents living below the federal poverty level for each census tract was also obtained from ACS using the 5 year estimate for 2009 to In the analysis, neighborhood poverty level was assigned to each death based on residence within each St. Louis County 2010 census tract. Each census tract was assigned one of four categories of percent below federal poverty level 4 : Low (0 to < 10 percent); Medium (10 to <20 percent); High (20 to <30 percent); and Very high (30 to 100 percent). Age adjusted and age specific rates and 95% confidence intervals were calculated in Microsoft Excel using population estimates from ACS. The rates were ageadjusted to the 2000 U.S. population 5. Geographic regions were determined from St. Louis County Planning division region maps by assigning each census tract a matching region. Maps were generated using ArcGIS for the vital statistics data for rates by zip code, and geographic regions. St. Louis County Opioid Epidemic Response The Saint Louis County Department of Public Health (DPH) and its partners are working to address the opioid epidemic through a variety of activities and programs: Surveillance Epidemiologists at DPH quantify the epidemic through regular surveillance and data analysis. This work tracks patterns in morbidity and mortality across the region, investigates risk factors that are linked to increased burden of opioid misuse, and helps DPH plan interventions that target the most high risk communities. These surveillance activities also help DPH track trends over time. Prevention DPH runs a county wide Prescription Drug Monitoring Program (PDMP), which allows healthcare providers to access patients prescription history to facilitate quality clinical decision making. Prescribers can ensure patients are not receiving dangerous doses of opioids and identify patients who are struggling with opioid use disorder. As of March 2018, 79% of Missouri s population lives in jurisdictions that participate in the PDMP. Through the PDMP, DPH is also able to disseminate resources to providers about safer prescribing practices. DPH and a number of other organizations including the National Council on Alcoholism and Drug Abuse (NCADA), the Missouri Network for Opiate Reform & Recovery, and the Alliance for Healthy Communities raise awareness about the risks of opioid overuse and empower community members to advocate for their own health.

20 Drug overdose deaths Page 20 of 33 Harm Reduction A number of initiatives have been put into place to mitigate health consequences for people already struggling with opioid overuse. The 911 Good Samaritan Law (RSMO ) grants immunity from arrest and prosecution for possession of drugs or paraphernalia and limited other crimes to anyone who calls 911 seeking to help an overdose victim. The Missouri Department of Health and Senior Services issued a statewide standing order enabling any pharmacist to dispense naloxone without a prescription. The MO HOPE project and other grant funded initiatives help expand naloxone access to those likely to witness an overdose such as first responders (fire departments, police departments, and EMS), current drug users, families and friends of drug users, and other interested community groups. Treatment and Recovery Medication Assisted Treatment (MAT), the most effective treatment for opioid use disorder, involves combining psychosocial support with medications such as buprenorphine/naloxone, naltrexone, or methadone. The cost of treatment and provider capacity are both barriers to access. The State Targeted Response grant has expanded training for providers and funding for treatment with a focus on uninsured patients. DPH helps promote training to increase the number of area providers equipped to offer MAT and is streamlining referral procedures so patients can find the help they need when they need it. An initiative to connect patients with crisis counselors and referral to treatment in emergency departments is connecting patients to care directly after an overdose. Behavioral Health Response, the Behavioral Health Network, the Missouri Coalition for Community Behavioral Healthcare, and other area organizations are working to expand access to treatment and recovery services. Community Resources If you or someone you know is struggling with opioid or heroin abuse please contact any of the following resources in Saint Louis County: Behavioral Health Response 24/7 Crisis Hotline: SSM Behavioral Health Services, Central Intake/Assessment and Referral Center: Bridgeway Behavioral Health: MO Community Mental Health Liaison: Provident Life Crisis Services 24/7 Hotline: Narcotics Anonymous 24/7 Helpline: National Council on Alcoholism and Drug Abuse: BJC Behavioral Health (St. Louis County Residents): (Day); (Night) Preferred Family Healthcare: (Day); (Night)

21 Drug overdose deaths Page 21 of 33 References 1. Hedegaard H, Chen LH, Warner M. Drug poisoning Deaths Involving Heroin: United States, NCHS Data Brief, 2015(190): p Seth P, Scholl L, Rudd RA, Bacon S. Overdose Deaths Involving Opioids, Cocaine, and Psychostimulants United States, MMWR Morb Mortal Wkly Rep 2018; 67: DOI: 3. U.S. Department of Justice Drug Enforcement Administration. Drugs of Abuse Edition: A DEA Resource Guide Rudd, R.A., et al., Increases in drug and opioid involved overdose deaths United States, MMWR Morb Mortal Wkly Rep : DOI: 5. Toprani A, Hadler JL. Selecting and applying a standard area based socioeconomic status measure for public health data: Analysis for New York City. New York City DOHMH: Epi Research Report, May Klein RJ, Schoenborn CA. Age adjustment using the 2000 projected U.S. population. Healthy People Statistical Notes, no. 20. Hyattsville, Maryland: National Center for Health Statistics. January Centers for Disease Control and Prevention. Injury Prevention & Control: Prescription Drug Overdose. May Office of the Associate Director for Communications (OADC), Centers for Disease Control and Prevention. Today s heroin epidemic. July Suggested citation Dalidowitz Dame L, Tutlam N, Cohen R, Kret J, Wang Y. Drug overdose deaths, St. Louis County, Missouri. Chronic Disease Epidemiology (CDE) program profile, no 7. St. Louis County, MO: Department of Public Health. February 2018.

22 Drug overdose deaths Page 22 of 33 Appendix 1: Drug poisoning deaths for individual years Table 1.1. Drug poisoning deaths per 100,000 population, St. Louis County, Rate 95% CI Count Rate 95% CI Count Rate 95% CI Count Rate 95% CI Count Rate 95% CI Count St. Louis County to to to to to Age Group < 18 years 0.4* 0.0 to * 0.3 to * 0.5 to * 0.5 to to 3.9* years to to to to to years to to to to to years to to to to to years and over to to to to to Gender Male to to to to to Female to to to to to Race Black/African American to to to to to White to to to to to Neighborhood Poverty Very High 21.1* 9.7 to * 9.9 to to * 10.2 to to High to to to to to Medium to to to to to Low to to to to to Geographic Area Central to to to to to Inner North to to to to to Outer North to to to to to South to to to to to West to to to to to Comparisons: Higher than St. Louis County rate Lower than St. Louis County rate Notes: Source: Missouri Department of Health and Senior Services (MoDHSS), Bureau of Vital Statistics. Case Definition: International Classification of Diseases, Tenth Revision (ICD 10) underlying cause poisoning codes X40 X44 (unintentional), X60 X64 (suicide), X85 (homicide), or Y10 Y14 (undetermined intent). Rates are age adjusted to the 2000 US population (not including Age Group rates). CI = Confidence. *Too few cases to meet precision standard (relative standard error <30%); interpret with caution. Too few cases to protect confidenality and/or report reliable rates.

23 Drug overdose deaths Page 23 of 33 Appendix 2: Drug overdoses involving select drug types for individual years Table 2.1. Drug overdose deaths involving cocaine, unspecified narcotics, benzodiazepines, psychostimulants with abuse potential, and other drugs, per 100,000 population, St. Louis County, Rate 95% CI Count Rate 95% CI Count Rate 95% CI Count Rate 95% CI Count Rate 95% CI Count Cocaine to to * 0.5 to to to Unspecified Narcotics 0.8* 0.3 to to * 0.5 to * 0.1 to * 0.4 to Benzodiazepines 0.7* 0.3 to to * 0.3 to * 0.5 to * 0.5 to Psychostimulants with abuse potential 0.2* 0.0 to * 0.3 to * 0.3 to * 0.1 to to Other Drugs to to to * 0.2 to to Rates are age adjusted to the 2000 US population (not including Age Group rates). CI = Confidence. *Too few cases to meet precision standard (relative standard error <30%); interpret with caution. Saint Louis County Department of Public Health June 2018

24 Drug overdose deaths Page 24 of 33 Table 2.2. Drug overdose deaths involving cocaine, per 100,000 population, St. Louis County, and average Rate 95% Confidence Count per Rate 95% Confidence Count per Rate 95% Confidence Count per year St. Louis County to to to Age Group < 18 years to to to years 0.5* 0.1 to 1.3 < 1 0.7* 0.1 to * 0.1 to years to to to years to to to years and over to to to Sex Male to to to Female to to to Race/Ethnicity Black/African American to to to White to to to Neighborhood Poverty Very High 1.5* 0.3 to 3.7 < 1 2.9* 1.2 to 5.7 < 1 4.3* 1.9 to High 0.5* 0.1 to 1.4 < 1 1.7* 0.7 to 3.1 < to Medium to to to Low to to to Geographic Area Central 1.5* 0.7 to * 0.6 to * 0.8 to Inner North to to to Outer North 0.8* 0.4 to to to South 0.7* 0.2 to * 0.1 to * 0.1 to West 0.6* 0.2 to * 0.3 to to Comparisons: Higher than St. Louis County rate Lower than St. Louis County rate Notes: Source: Missouri Department of Health and Senior Services (MoDHSS), Bureau of Vital Statistics. Case Definition: International Classification of Diseases, Tenth Revision (ICD 10) underlying cause poisoning codes X40 X44 (unintentional), X60 X64 (suicide), X85 (homicide), or Y10 Y14 (undetermined intent) and multiple cause code T40.5. Rates are age adjusted to the 2000 US population (not including Age Group rates). *Too few cases to meet precision standard (relative standard error <30%); interpret with caution. Saint Louis County Department of Public Health June 2018

25 Drug overdose deaths Page 25 of 33 Table 2.3. Drug overdose deaths involving other and unspecified narcotics per 100,000 population, St. Louis County, , , average Rate 95% Confidence Count per Rate 95% Confidence Count per Rate 95% Confidence Count per year St. Louis County to to to Age Group < 18 years to to to years 0.2* 0.0 to 0.8 < to * 0.0 to 0.8 < years to to to years to to to years and over to 0.7 < to 0.7 < to 0.7 <1 Sex Male to to to Female to to to Race/Ethnicity Black/African American to to to Hispanic/Latino 2.8* 0.2 to 9.9 < 1 2.6* 0.1 to 8.4 < 1 2.5* 0.1 to 8.6 <1 White to to to Neighborhood Poverty Very High 1.9* 0.4 to * 0.7 to * 1.4 to High 0.5* 0.1 to * 0.3 to * 0.3 to Medium to to to Low to to to Geographic Area Central 0.5* 0.1 to * 0.1 to * 0.1 to 1.1 <1 Inner North to to to Outer North to * 0.5 to * 0.4 to South to to to West 0.6* 0.2 to * 0.1 to * 0.2 to Comparisons: Higher than St. Louis County rate Lower than St. Louis County rate Notes: Source: Missouri Department of Health and Senior Services (MoDHSS), Bureau of Vital Statistics. Case Definition: International Classification of Diseases, Tenth Revision (ICD 10) underlying cause poisoning codes X40 X44 (unintentional), X60 X64 (suicide), X85 (homicide), or Y10 Y14 (undetermined intent) and multiple cause code T40.6. Rates are age adjusted to the 2000 US population (not including Age Group rates). *Too few cases to meet precision standard (relative standard error <30%); interpret with caution. Saint Louis County Department of Public Health June 2018

26 Drug overdose deaths Page 26 of 33 Table 2.4. Drug overdose deaths involving benzodiazepines per 100,000 population, St. Louis County, , , and average Rate 95% Confidence Count per Rate 95% Confidence Count per Rate 95% Confidence Count per year St. Louis County to to to Age Group < 18 years 0.1* 0.0 to 0.3 < 1 0.2* 0.0 to 0.5 < 1 0.2* 0.0 to 0.5 < years 0.7* 0.1 to * 0.1 to * 0.5 to years to to to years to to to years and over 0.3* 0.0 to 0.7 < 1 0.2* 0.0 to 0.7 < to 0.9 <1 Sex Male to to to Female 0.3* 0.1 to * 0.2 to to Race/Ethnicity Black/African American 0.2* 0.0 to 0.6 < 1 0.2* 0.0 to 0.6 < 1 0.1* 0.0 to 0.5 <1 White to to to Neighborhood Poverty Very High to to to High 0.4* 0.0 to 1.4 < 1 0.4* 0.0 to 1.4 < 1 0.8* 0.2 to 1.9 <1 Medium to to to Low to to to Geographic Area Central 0.5* 0.1 to * 0.3 to * 0.2 to Inner North 1.0* 0.4 to * 0.4 to * 0.2 to Outer North 0.4* 0.1 to * 0.0 to * 0.2 to South to to to West 0.3* 0.1 to * 0.2 to * 0.2 to Comparisons: Higher than St. Louis County rate Lower than St. Louis County rate Notes: Source: Missouri Department of Health and Senior Services (MoDHSS), Bureau of Vital Statistics. Case Definition: International Classification of Diseases, Tenth Revision (ICD 10) underlying cause poisoning codes X40 X44 (unintentional), X60 X64 (suicide), X85 (homicide), or Y10 Y14 (undetermined intent) and multiple cause code T42.4. Rates are age adjusted to the 2000 US population (not including Age Group rates). Saint Louis County Department of Public Health June 2018

27 Drug overdose deaths Page 27 of 33 Table 2.5. Drug overdose deaths involving psychostimulants per 100,000 population, St. Louis County, , , and average Rate 95% Confidence Count per Rate 95% Confidence Count per Rate 95% Confidence Count per year St. Louis County to to to Age Group < 18 years 0.1* 0.0 to 0.3 < 1 0.1* 0.0 to 0.3 < 1 0.1* 0.0 to 0.3 < years 0.2* 0.0 to 0.8 < 1 0.2* 0.0 to 0.8 <1 0.2* 0.0 to 1.8 < years to to to years to to to years and over to to 0.0 < 1 0.1* 0.0 to 0.5 <1 Sex Male to to to Female 0.4* 0.2 to * 0.2 to to Race/Ethnicity Black/African American to * 0.0 to 0.5 < 1 0.1* 0.0 to 0.4 <1 White to to to Neighborhood Poverty Very High to to * 0.0 to 3.0 <1 High 0.9* 0.2 to * 0.3 to * 0.3 to Medium 0.2* 0.0 to * 0.1 to * 0.3 to Low to to to Geographic Area Central 0.5* 0.1 to * 0.1 to * 0.1 to 1.4 <1 Inner North 0.5* 0.2 to * 0.2 to * 0.4 to Outer North 0.3* 0.1 to * 0.1 to * 0.1 to South 0.8* 0.3 to * 0.3 to * 0.5 to West 0.3* 0.1 to * 0.1 to to Comparisons: Higher than St. Louis County rate Lower than St. Louis County rate Notes: Source: Missouri Department of Health and Senior Services (MoDHSS), Bureau of Vital Statistics. Case Definition: International Classification of Diseases, Tenth Revision (ICD 10) underlying cause poisoning codes X40 X44 (unintentional), X60 X64 (suicide), X85 (homicide), or Y10 Y14 (undetermined intent) and multiple cause code T43.6. Rates are age adjusted to the 2000 US population (not including Age Group rates). *Too few cases to meet precision standard (relative standard error <30%); interpret with caution. Saint Louis County Department of Public Health June 2018