Leveraging data to monitor the rise of cocaine and methamphetamine in Philadelphia Lia N. Pizzicato, MPH Substance Use Epidemiologist Philadelphia Department of Public Health
Learning Objectives 1 2 3 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
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
State of the Crisis
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) 0 5 10 15 20 25 30 35 40 45 50 Overdose Rate per 100,000 Residents CDC WONDER, 2016
Drug overdoses caused 4x as many deaths as homicides in 2017 Peak AIDS Deaths (935)
<18 18-24 25-34 35-44 45-54 55-64 65+ Female Male White Black Hispanic Other Number of Deaths All geographic regions and demographic groups are affected Demographics of Overdose Deaths 1000 900 800 700 600 500 400 300 200 100 0 Age Group Gender Race/Ethnicity
Unintentional drug deaths (N) 1,217 people died from drug overdoses in 2017 400 350 300 250 200 150 100 50 Non-opioid related Opioid related 0 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 2014 2015 2016 2017 Source: Philadelphia Department of Public Health
Cocaine Trends
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% 2010 2011 2012 2013 2014 2015 2016 2017 Source: Philadelphia Department of Public Health
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% 2010 2011 2012 2013 2014 2015 2016 2017 Source: Philadelphia Department of Public Health
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% 2010 2011 2012 2013 2014 2015 2016 2017 Source: Philadelphia Department of Public Health
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?
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
Age Category p<0.01 100% 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 35-54 years 14-34 years Source: Philadelphia Department of Public Health
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
Race/Ethnicity 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 5% 71% 23% p<0.01 20% 26% 53% 16% 22% 62% Cocaine only Cocaine & Fentanyl Cocaine & Heroin (± Fentanyl) Other Hispanic Black White Source: Philadelphia Department of Public Health
Evidence of Injection p<0.01 100% 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
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 Q4 2016 2017 Percentage Containing Heroin Percentage Containing Fentanyl Source: DEA National Forensic Laboratory Information System
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...
Crack Cocaine Overdose Outbreak & Rapid Response
Background on Rapid Response Final recommendations May 19, 2017 Establish use of real-time data to support a rapid response plan
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
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 6/18/2018 16 Surge Detected on June 18, 2018 at Local Hospital 14 12 10 8 6 4 2 0 Count Exponential Moving Average Threshold Exponential Moving Average Predicted Value Source: DEA ARCOS
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
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
Response Health Alert Released by Health Department Media Disseminated Warnings Health Department Engaged Neighborhoods affected
Source: Philadelphia Inquirer
Methamphetamine Trends
Grams sold 25000 Stimulant sales have also increased dramatically in Philadelphia 20000 15000 10000 5000 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Methylphenidate (Ritalin) Amphetamine (Adderall) Lisdexamfetamine (Vyvanse) Source: DEA ARCOS
Number of Methamphetamine Involved Overdose Deaths Methamphetamine involved overdose deaths are increasing in Philadelphia 80 70 72 60 50 40 34 30 20 10 12 6 9 9 16 19 0 2010 2011 2012 2013 2014 2015 2016 2017
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% 2010 2011 2012 2013 2014 2015 2016 2017
Results from a Survey of People who Use Drugs
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
18-24 25-34 35-44 45-54 55-64 65 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
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
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
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
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
Conclusions
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
www.phila.gov/opioids For more information: Lia N. Pizzicato, MPH Substance Use Epidemiologist Philadelphia Department of Public Health Lia.Pizzicato@Phila.Gov