Milwaukee County Opioid Related Overdose Report 2012 2016 MILWAUKEE C O P E COMMUNITY OPIOID PREVENTION EFFORT For addi onal informa on or if you have ques ons about the data presented in this report, please contact: Nicole Fumo, MPH mkecommunityopioid@gmail.com Visit our website: h p://www.mcw.edu/milwaukeecope Follow us on Facebook: h ps://www.facebook.com/milwaukeecommunityopioidpreven oneffort/ Version Release Date: 6.21.2017 1
This report shows that opioid related overdose deaths con nue to rise in Milwaukee County. The deaths only illustrate a small part of the effect the opioid epidemic has on the Milwaukee community. In fact, in 2015, for every death, there were more than 6 addi onal people who experienced an overdose that required Naloxone. In 2016, for every death there were approximately 3 people treated by EMS with Naloxone who survived. It is unknown how many people in our community have substance use disorder, but in 2016 over 930 people requested assistance from the Milwaukee Behavioral Health Division s Community Access and Recovery Services. While the largest propor on of those who experience a fatal overdose are older white men, this epidemic is touching every sector of our county and no geographic region, race, or age group is spared. The majority of those who die are found to have ingested mul ple drugs that contributed to their death. Further, there has been a steep rise in fentanyl related overdose deaths. Alarmingly, among those who survived their overdose a er receiving Naloxone, approximately one quarter did not access the EMS system. Of those who died from an opioid overdose, the majority were not iden fied un l a er it was too late to a empt resuscita on or administer Naloxone either because the vic m was alone or thought to be sleeping. There is no singular solu on for comba ng this public health crisis. To reduce the number of overdose deaths we must con nue to reduce recrea onal use, work with providers to prevent those in pain from developing substance use disorder, create systems for ensuring that individuals suffering from substance use disorder have access to comprehensive treatment, and work to ensure that those who overdose have access to lifesaving treatments. Executive Summary Data Source: Milwaukee County Medical Examiner Opioid related overdose deaths, Milwaukee County Office of Emergency Management s (OEM) Countywide EMS Medical Record Database, and AIDS Resource Center of Wisconsin Needle Exchange Program Surveys Version Release Date: 6.21.2017 2
Summary of Milwaukee County Medical Examiner Data for Opioid Related Overdose Deaths Version Release Date: 6.21.2017 3
Opioid Related Overdose Deaths for Years 2012 2016 Data Source: Milwaukee County Medical Examiner Opioid related overdose deaths. Version Release Date: 6.21.2017 4
Opioid Related Overdose Deaths by Age Range for Years 2012 2016 The majority of opioid related overdose deaths, 88%, occur between 20 59 years of age. Data Source: Milwaukee County Medical Examiner Opioid related overdose deaths. Version Release Date: 6.21.2017 5
Opioid Related Overdose Deaths by Race/ Ethnicity Opioid Related Overdose Deaths by Sex 2012 2016 2012 2016 Of the 1070 opioid related overdose deaths between 2012 and 2016, 71% were white and 62% were male. Data Source: Milwaukee County Medical Examiner Opioid related overdose deaths. Version Release Date: 6.21.2017 6
Opioid Related Overdose Deaths by Age Range and Race/Ethnicity for Years 2012 2016 Almost 50% of all opioid related overdose deaths occurred among white vic ms between the ages of 20 49. While the age distribu on of white overdose deaths mirrors the overall age distribu on, black overdose deaths skew older with 57% occurring between the ages of 40 59. Data Source: Milwaukee County Medical Examiner Opioid related overdose deaths. Version Release Date: 6.21.2017 7
Percent of Opioid Related Overdose Deaths Occurring at the Vic ms Residence in Milwaukee County for Years 2012 2016 Year 2012 2013 2014 2015 2016 Death at residence 106 131 150 162 190 Total opioid deaths 144 181 220 231 294 Percent 74% 72% 68% 70% 65% From 2012 through 2016, 69% of people who experienced a fatal opioid related overdose died in their place of residence. 14 cases did not have a place of residence recorded. Version Release Date: 6.21.2017 Data Source: Milwaukee County Medical Examiner Opioid related overdose deaths. 8
Drugs A ributed to Cause of Death Based on Toxicology Results for Years 2012 2016 Toxicology Results Data Source: Milwaukee County Medical Examiner Opioid related overdose deaths. Number of Cases Other Drug, Other Opioid 203 Heroin 164 Other Drug, Heroin 125 Other Opioid 72 Other Drug, Cocaine, Heroin 47 Other Drug, Morphine/Codeine 44 Cocaine, Heroin 40 Other Drug, Other Opioid, Heroin 38 Other Drug, Morphine/Codeine, Other Opioid 38 Fentanyl 37 Morphine/Codeine 35 Morphine/Codeine, Other Opioid 24 Heroin, Other Opioid 23 Other Drug, Cocaine, Other Opioid 17 Other Drug, Fentanyl 16 Cocaine, Other Opioid 14 Fentanyl, Heroin 14 Other Drug, Fentanyl, Other Opioid 13 Other Drug, Fentanyl, Cocaine 11 Fentanyl, Other Opioid 9 Fentanyl, Cocaine, Heroin 9 Other Drug, Cocaine, Other Opioid, Heroin 9 Other Drug, Fentanyl, Heroin 9 Fentanyl, Cocaine 7 Other Drug, Fentanyl, Cocaine, Heroin 6 Fentanyl, Morphine/Codeine 5 Other Drug, Morphine/Codeine, Cocaine 5 17 combina ons with less than 5 cases are not 36 represented in this table Percent of Total Deaths (n=1070) 19% Version Release Date: 6.21.2017 9 15% 12% 7% 4% 4% 4% 4% 4% 3% 3% 2% 2% 2% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% <1% <1% 3% Notes on Drug Categories Fentanyl: includes; Acetal Fentanyl, Fentanyl, Fural Fentanyl. Morphine/Codeine: Cannot be dis nguished from heroin depending on me of death. Other Opioid: includes; Buprenorphine, Hydrocodone, Hydromorphone, Loperamide, Methadone, Oxymorphone, Oxycodone, Tramadol. The vic m may have taken 1 or more of these drugs. Other Drug: includes; Alcohol, Alprazolam, Amitriptyline, Amphetamine, Carbamazepine, Carisoprodol, Chlordiazepoxide, Citalopram, Clonazepam, Cyclobenzaprine, Desipramine, Diazepam, Diphenhydramine, Doxylamine, Duloxe ne, Ephedrine, Fluoxe ne, Gabapen n, Hydroxyzine, Ketamine, Leve racetam, Lorazepa, MDMA, Meprobamate, Mirtazapine, Nordiazepam, Olanzapine, Oxazepam, Paroxe ne, Phenobarbital, Pseudoephedrine, Que apine, Sertraline, Temazepam, Topiramate, Trazadone, Venlafaxine, Ziprasidone, Zolpidem. The vic m may have taken 1 or more of these drugs.
Fi een Most Common Drug Combina ons A ributed to Cause of Death Based on Toxicology Results for Years 2012 2016 Drug categories defined on page 14 Data Source: Milwaukee County Medical Examiner Opioid related overdose deaths. Version Release Date: 6.21.2017 10
Number of Cases with a Single Drug A ributed to the Cause of Death Compared to Those with a Combina on of Two or More Drugs for Years 2012 2016 Of the 1070 opioid related overdose deaths from 2012 2016, 774 (72%) died from a combina on of 2 or more drugs. Note: Single Type of Other Opioid includes vic ms who died with only one opioid in their system: Buprenorphine, Hydrocodone, Hydromorphone, Loperamide, Methadone, Oxycodone, Oxymorphone, or Tramadol. Data Source: Milwaukee County Medical Examiner Opioid related overdose deaths. Version Release Date: 6.21.2017 11
Overdose Deaths Where Fentanyl was A ributed as a Cause of Death Alone or In Combina on with Other Drugs for Years 2012 2016 Of the 294 opioid related overdose deaths in 2016, 33% involved the drug fentanyl. In 2015, only 13% of opioid related overdose deaths involved fentanyl. Data Source: Milwaukee County Medical Examiner Opioid related overdose deaths. Version Release Date: 6.21.2017 12
Overdose Deaths Where Fentanyl was A ributed as a Cause of Death Alone or In Combina on with Other Drugs by Age Range for Years 2012 2016 Overdose Deaths Where Heroin was A ributed as a Cause of Death Alone or In Combina on with Other Drugs by Age Range for Years 2012 2016 Data Source: Milwaukee County Medical Examiner Opioid related overdose deaths. Version Release Date: 6.21.2017 13
Loca on of Opioid Related Overdose Death in Milwaukee County for Years 2013 2016 2013 2014 2015* 2016 *One case outside of Milwaukee County LEGEND Death Data Source: Milwaukee County Medical Examiner Opioid related overdose deaths. Version Release Date: 6.21.2017 14
Overdose Loca on for Opioid Related Deaths in Milwaukee County for Year 2016 Legend Opioid Death Density 0 1 1 2 2 4 4 5 5 6 6 8 8 9 9 10 10 12 12 13 Low High LEGEND Overdose Loca on Version Release Date: 6.21.2017 Data Source: Milwaukee County Medical Examiner Opioid related overdose deaths. 15
Residence of Opioid Related Overdose Vic ms Who Died in Milwaukee County for Years 2012 2016 Of the 1070 opioid related deaths in Milwaukee County, 66 (6%) had a residence outside of the county and 27 (2.5%) lived outside of Wisconsin. 14 (1.3%) decedents who died of an opioidrelated overdose in Milwaukee County did not have a residen al address and are not included in the map. LEGEND Residence Data Source: Milwaukee County Medical Examiner Opioid related overdose deaths. Version Release Date: 6.21.2017 16
Resuscita on a empted prior to declaring death (documented=294, 100%) Vic m transported to the hospital (documented=294, 100%) Number of Cases with The Factor Percent of all Deaths (N=294) 123 42% 42% 43 15% 15% Vic m transported to the hospital by EMS 31 11% 72% Received Naloxone during resuscita on (documented=252, 86%) 32 11% 43% By EMS 20 7% 63% By bystander 7 2% 22% By hospital provider 3 1% 9% By Police 2 <1% 6% Drug paraphernalia visible at the me of resuscita on (documented=70) Vic m alone at the me of overdose (documented=261, 89%) 54 18% 77% 188 64% 72% Vic m not alone at the me of overdose 73 25% 28% Vic m thought to be sleeping at the me of death 28 10% 38% Loca on of overdose (documented=294, 100%) Review of Medical Examiner Narra ves for all 2016 Opioid Related Overdose Deaths: Circumstances Surrounding the Overdose That May Have Contributed to Death Home/Residence 247 84% 84% In a Vehicle 15 5% 5% Outside 10 3% 3% Public Building 10 3% 3% Hotel/Motel 5 2% 2% Physician Office/Clinic/Hospital 3 1% 1% Unknown 4 1% 1% Percent of Total Cases With the Factor Documented that Were Posi ve for the Factor* *Note: This data was abstracted from unstructured narra ves. Not all variables were documented in every case. When not all cases have a variable documented it may or may not mean that the factor was not present for that case. Therefore the percent of cases for a given factor is given for all deaths in 2016 and for all cases with the factor documented. Version Release Date: 6.21.2017 17
Review of Medical Examiner Narra ves for all 2016 Opioid Related Overdose Deaths: Vic ms Documented Medical History Prior to Death History of tobacco use (documented=225, 77%) History of substance use (documented=228, 78%) Number of Cases with The Factor Percent of all Deaths (N=294) 188 64% 84% 282 96% 98% Alcohol 171 58% 61% Heroin 158 54% 56% Prescrip on Other 109 37% 39% Other 103 35% 37% Prescrip on Opioids 101 34% 36% Cocaine 85 29% 30% Benzodiazepines 75 26% 27% Marijuana 57 19% 20% Unknown 23 8% 8% Methamphetamines 7 2% 2% Percent of Total Cases With the Factor Documented that Were Posi ve for the Factor* History of previous overdose (documented=76, 26%) History of substance use disorder treatment or rehabilita on (documented=73, 25%) History of pain management (documented=53, 18%) 50 17% 66% 71 24% 97% 49 17% 92% *Note: This data was abstracted from unstructured narra ves. Not all variables were documented in every case. When not all cases have a variable documented it may or may not mean that the factor was not present for that case. Therefore the percent of cases for a given factor is given for all deaths in 2016 and for all cases with the factor documented. Version Release Date: 6.21.2017 18
Review of Medical Examiner Narra ves for all 2016 Opioid Related Overdose Deaths: Vic ms Documented Social History Prior to Death Marital status (documented=162, 55%) Number of Cases with The Factor Percent of all Deaths (N=294) Married/in a rela onship 96 33% 60% Single 33 11% 20% Divorced/separated 29 10% 18% Widowed 4 1% 2% Employment status (documented =75, 26%) Employed 41 14% 55% Unemployed 30 10% 40% On disability 4 1% 5% Vic m was homeless (documented =294, 100%) Vic m had children (documented=116, 39%) 7 7% 7% 100 34% 86% Percent of Total Cases With the Factor Documented that Were Posi ve for the Factor* *Note: This data was abstracted from unstructured narra ves. Not all variables were documented in every case. When not all cases have a variable documented it may or may not mean that the factor was not present for that case. Therefore the percent of cases for a given factor is given for all deaths in 2016 and for all cases with the factor documented. Version Release Date: 6.21.2017 19
Summary of Opioid Related Overdose Deaths in Milwaukee County All Opioid Overdoses 2012 2016 2012 2013 2014 2015 2016 Total 1070 144 181 220 231 294 Frequency Percent Frequency Percent Frequency Percent Frequency Percent Frequency Percent Frequency Percent Sex Male 667 62% 87 60% 102 56% 133 60% 149 65% 196 67% Female 402 38% 57 40% 79 44% 87 40% 81 35% 98 33% Age Range under 9 8 1% 0 0% 2 1% 0 0% 1 0% 5 2% 10 19 17 2% 2 1% 5 3% 1 0% 4 2% 5 2% 20 29 217 20% 23 16% 35 19% 50 23% 45 19% 64 22% 30 39 270 25% 36 25% 32 18% 48 22% 64 28% 90 31% 40 49 221 21% 30 21% 53 29% 44 20% 46 20% 48 16% 50 59 235 22% 42 29% 42 23% 49 22% 42 18% 60 20% 60 69 88 8% 9 6% 9 5% 24 11% 26 11% 20 7% 70 79 12 1% 2 1% 3 2% 3 1% 3 1% 1 0% 80 89 1 0% 0 0% 0 0% 1 0% 0 0% 0 0% 90 99 1 0% 0 0% 0 0% 0 0% 0 0% 1 0% Race/Ethnicity White 758 71% 95 66% 126 70% 157 71% 169 73% 211 72% Black 216 20% 33 23% 34 19% 46 21% 47 20% 56 19% Hispanic 74 7% 11 8% 16 9% 14 6% 9 4% 24 8% Other 21 2% 5 3% 5 3% 3 1% 5 2% 3 1% Data Source: Milwaukee County Medical Examiner Opioid related overdose deaths. Version Release Date: 6.21.2017 20
Summary of Milwaukee County Emergency Medical Services Data for Suspected Opioid Related Overdose Version Release Date: 6.21.2017 21
EMS Transport Des na on for Suspected Opioid Related Overdose Vic ms Who Received Naloxone for Years 2012 2016 Transport Des na on Number of calls (N=3,519) Hospital Emergency Department 3,156 (90%) Medical Examiner 161 (4.6%) Refused Transport 190 (5.4%) Other/Unknown 12(<1%) Data Source: Milwaukee County Office of Emergency Management s (OEM) Countywide EMS Medical Record Database Version Release Date: 6.21.2017 22
Loca on of EMS Responses for Suspected Opioid Related Overdose Based on Naloxone Administra on for Years 2014 2016 2014 2015 Data Source: Milwaukee County Office of Emergency Management s (OEM) Countywide EMS Medical Record Database LEGEND EMS Response Version Release Date: 6.21.2017 23 2016
Comparison of Patient Residence and Overdose Location by Zip Code for all EMS Responses in Milwaukee County Between 2014 and 2015 for Suspected Opioid Related Overdose Based on Naloxone Administration EMS pa ents whose overdose loca on was in the same zip code as their residence. 62% EMS pa ents whose overdose loca on was NOT in the same zip code as their residence, and residence was within Milwaukee County. 27% EMS pa ents whose overdose loca on was NOT in the same zip code as their residence, and residence was outside of Milwaukee County. 11% Between 2014 and 2016 there were 3,519 EMS responses in Milwaukee County for a suspected opioid related overdose based on naloxone being administered. Among those pa ents, 89% had a residence zip code within Milwaukee County. Further, 62% of overdoses occurred in the same zip code as the vic m s documented residence. Version Release Date: 6.21.2017 24
Summary of EMS Responses for Suspected Opioid Related Overdose Based on Naloxone Administra on Sex All Suspected Opioid Overdoses 2014 2016 2014 2015 2016 Total 3519 1175 1018 1326 Frequency Percent Frequency Percent Frequency Percent Frequency Percent Male 2178 62% 676 58% 650 64% 852 64% Female 1336 38% 495 42% 367 36% 474 36% Age Range under 9 10 <1% 1 <1% 3 <1% 6 <1% 10 19 80 2% 26 2% 27 3% 27 2% Race/Ethnicity 20 29 989 28% 276 23% 315 31% 398 30% 30 39 798 23% 231 20% 219 22% 348 26% 40 49 514 15% 172 15% 154 15% 188 14% 50 59 542 15% 198 17% 161 16% 183 14% 60 69 300 9% 111 9% 80 8% 109 8% 70 79 154 4% 84 7% 32 3% 38 3% 80 89 102 3% 59 5% 21 2% 22 2% 90 99 30 1% 17 1% 6 1% 7 1% White 1484 42% 483 41% 457 45% 544 41% Black 482 14% 196 17% 142 14% 144 11% Hispanic 118 3% 49 4% 27 3% 42 3% Other 24 1% 7 1% 4 <1% 13 1% Unknown 1411 40% 440 37% 388 38% 583 44% Data Source: Milwaukee County Office of Emergency Management s (OEM) Countywide EMS Medical Record Database Version Release Date: 6.21.2017 25
EMS Responses for Suspected Opioid Related Overdose in the North Shore Region of Milwaukee County for Years 2014 2016 EMS responses in this analysis were iden fied using EMS medical record data that was submi ed to Milwaukee County s Office of Emergency Management (OEM) (N=102). Cases iden fied were those that received a response from a Fire Department based EMS Unit and were documented to have received Naloxone. In the North Shore Region of Milwaukee, they use the data management and analysis tool First Watch (h ps://www.firstwatch.net/what we do/ems/) to iden fy overdoses in their region. First Watch reviews both key variables (e.g., primary/secondary impression and medica on administra on) and narra ves for key words to iden fy poten al opioid overdose vic ms. We compared our iden fied cases from the Milwaukee County OEM EMS medical records database to those from the First Watch search and found that the two methods for iden fying cases were equivalent, with the excep on of one case. This case was likely not iden fied in the county data due to a documenta on error. LEGEND EMS Response Loca on Data Source: Milwaukee County Office of Emergency Management s (OEM) Countywide EMS Medical Record Database Version Release Date: 6.21.2017 26
Comparison of Opioid Related Overdose Data from Milwaukee County Medical Examiner and Milwaukee County EMS Version Release Date: 6.21.2017 27
Comparison of Opioid Related Overdose Deaths and EMS Naloxone Administra ons for Years 2011 2016 * *EMS protocol indicates that best prac ce is to address the cardiac arrest prior to administra on of Naloxone. This informa on was highlighted in a 2014 EMS refresher. Therefore, all cardiac arrest cases were removed to maintain an equal comparison. Over me, EMS Naloxone administra ons have stayed rela vely steady while overdose deaths con nue to climb. Data Source: Milwaukee County Medical Examiner Opioid related overdose deaths. Data Source: Milwaukee County Office of Emergency Management s (OEM) Countywide EMS Medical Record Database Version Release Date: 6.21.2017 28
Comparison of 2016 Medical Examiner and Milwaukee County EMS Data by Race/Ethnicity and Sex EMS Response for Suspected Opioid Overdose based on Naloxone Administra on by Race/ Ethnicity Opioid Related Overdose Deaths by Race/ Ethnicity There were a large number of EMS cases with unknown/not specified race, the race distribu on among those that were known (N=743) were consistent with the race distribu on of overdose deaths. When unknown cases were removed, the distribu on was: White: 73%, Black: 19%, Hispanic/La no: 6%. EMS Response for Suspected Opioid Overdose based on Naloxone Administra on by Sex Opioid Related Overdose Deaths by Sex Data Source: Milwaukee County Medical Examiner Opioid related overdose deaths. Data Source: Milwaukee County Office of Emergency Management s (OEM) Countywide EMS Medical Record Database Version Release Date: 6.21.2017 29
Comparison of 2016 Medical Examiner and Milwaukee County EMS Data by Age Range Opioid Related Overdose Deaths by Age Range EMS Responses for Suspected Opioid Related Overdose Based on Naloxone Administra on by Age Range In 2016, 22% of opioid related overdose deaths occurred among vic ms 20 29 years of age compared to 30% of EMS responses for suspected opioid related overdose for the same age range. Data Source: Milwaukee County Medical Examiner Opioid related overdose deaths. Data Source: Milwaukee County Office of Emergency Management s (OEM) Countywide EMS Medical Record Database Version Release Date: 6.21.2017 30
Loca on of EMS Responses for Suspected Opioid Related Overdose Based on Naloxone Administra on for Year 2016 Legend EMS Call Loca on Density Overdose Loca on for Opioid Related Deaths in Milwaukee County for Year 2016 0 1 Low 1 3 3 4 4 6 6 7 7 9 9 10 10 12 12 13 High Legend Opioid Death Density 0 1 Low 1 2 2 4 4 5 5 6 6 8 8 9 9 10 10 12 12 13 Version Release Date: 6.21.2017 31 High
Summary of Addi onal Opioid Related Data from the Milwaukee Community Version Release Date: 6.21.2017 32
Laypeople Overdose Reversal A empts Using Naloxone in Milwaukee County In 2015, 424 laypeople reported using Naloxone to reverse an overdose. This data was collected by the AIDS Resource Center of Wisconsin (ARCW) through self reported surveys collected by the Needle Exchange Program when replacement Naloxone was requested. Within the state of Wisconsin they recorded 1,135 peer saves. 2015 Self Reported Number of 0.4mg Naloxone doses given Intramuscularly by Laypeople to Reverse an Overdose 2015 Self Reported 9 1 1 Calls Following Laypeople Administering Naloxone to Reverse an Overdose In 2016, ARCW collected self reported data indica ng 192 overdose reversal a empts. This number is significantly lower than those reported in 2015 but is considered an under es mate. During 2016, the program was out of Naloxone for approximately two months, new staff were being trained on data collec on methods, and a new database was implemented. However, despite likely under repor ng, a similar propor on of individuals (12%) reported calling 9 1 1 at the me of the overdose. It is also important to note that based on addi onal survey ques ons, 6% reported taking the vic m to the hospital in 2016. Data Source: AIDS Resource Center of Wisconsin Needle Exchange Program Surveys Version Release Date: 6.21.2017 33
2016 Data from the Milwaukee Behavioral Health Division Community Access to Recovery Services 3,629 individuals sought assistance with a self reported primary substance of use Of those, 26% (n=938) reported heroin or another opioid as their primary substance of use. Primary Substance of Use Among All Individuals Seeking Assistance in 2016 Data Source: Milwaukee County Behavioral Health Division: Community Access and Recovery Services Version Release Date: 6.21.2017 34
Milwaukee Youth Risk Behavior Surveillance System (YRBSS) Survey Data This data reflects Milwaukee area students who par cipated in the Milwaukee survey in 2011 and 2013. The YRBSS monitors priority health risk behaviors among youth that could contribute to the leading causes of death, disability, and social problems in the Unites States. Centers for Disease Control and Preven on: High School Youth Risk Behavior Survey, Milwaukee 2011, 2013 Version Release Date: 6.21.2017 35