Opioid-Related Overdose in Milwaukee County MILWAUKEE C O P E COMMUNITY OPIOID PREVENTION EFFORT For additional information or if you have questions about the data presented in this report, please contact: Nicole Fumo, MPH mkecommunityopioid@gmail.com 1
Executive Summary This report shows that opioid-related overdose deaths are rising in Milwaukee County. However, the deaths only illustrate one small part of the effect the opioid epidemic has on the Milwaukee community. In fact, for every death, there are more than 6 additional people experiencing an overdose that require naloxone. In approximately one third of those cases, the emergency medical services system is not being accessed. While the largest proportion 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. Additionally, there has been a steep rise in fentanyl-related overdose deaths in the past year. The presence of these potent drugs may be known to the user, or it may be mixed into their drugs without their knowledge. There is no singular solution for combating this public health crisis. In order to significantly reduce the number of overdose deaths we must combat this epidemic at every level. We must continue to reduce recreational use, work with providers to prevent those in pain management from developing a substance use disorder, and create systems for ensuring that individuals suffering from substance use disorder have access to comprehensive treatment options. 231 Opioid Deaths ~1442 Opioid Overdoses Individuals Suffering from Opioid Use Disorder (2015) Data Source: Milwaukee County Office of Emergency Management s (OEM) Countywide EMS Medical Record Database (2015) Data Source: AIDS Resource Center of Wisconsin Needle Exchange Program Surveys (2015) 2
Opioid-Related Overdose Deaths by Year January 2012 - September 2016 220 231 181 191* 144 2012 2013 2014 2015 2016 *Data represents overdose deaths from January 1, 2016 September 24, 2016 3
Opioid-Related Overdose Deaths by Age Range January 2012- September 2016 236 219 191 203 83 7 15 11 1 1 0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90-99 The majority of opioid-related overdose deaths, 88%, occur between 20-59 years of age. 4
Opioid-Related Overdose Deaths by Age Range and Race/Ethnicity January 2012 September 2016 Almost 50% of all opioid-related overdose deaths occured among white victims between the ages of 20-49. While the distribution of white overdose deaths mirrors the overall distribution, black overdose deaths skew older with 45% occuring between the ages of 40-59. 5
Opioid-Related Overdose Deaths by Race/Ethnicity Opioid-Related Overdose Deaths by Sex 2012-2016 January 2012 September 2016 January 2012 September 2016 7% 2% 20% 71% White 38% Black Hispanic Other 62% Male Female Of the 967 opioid-related overdose deaths between January 1, 2012 and September 24, 2016, 71% were white and 62% were male. 6
Comparison of 2015 Medical Examiner and Milwaukee County EMS Data by Race and Sex 2015 EMS Response for Suspected Opioid Overdose based on Naloxone Administration by Race 2015 Opioid-Related Overdose Deaths by Race 4% 3% 20% White 38% White 45% Black Hispanic/Latino 73% Black Hispanic /Latino Other 3% 14% Unknown/Not Specified While there were a large number of cases with unknown races among EMS response data, the percent among those that were known (N=630) were consistent with race ratios of overdose deaths. When unknown cases were removed, the distribution was: White: 73%, Black: 23%, Hispanic/Latino: 4%. 2015 EMS Response for Suspected Opioid Overdose based on Naloxone Administration by Sex 2015 Opioid-Related Overdose Deaths by Sex 36% Male 35% Male 64% Female 65% Female Data Source: Milwaukee County Office of Emergency Management s (OEM) Countywide EMS Medical Record Database 7
Comparison of 2015 Medical Examiner and Milwaukee County EMS Data by Age Range 2015 Opioid-Related Overdose Deaths by Age Range 64 45 46 42 26 1 4 3 0 0 0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90-99 2015 EMS Responses for Suspected Opioid-Related Overdose Based on Naloxone Administration 315 219 154 161 80 3 27 32 21 6 0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90-99 In 2015, 19% of opioid-related overdose deaths occurred among victims 20-29 years of age compared to 31% of EMS responses for suspected opioidrelated overdose for the same age range. Data Source: Milwaukee County Office of Emergency Management s (OEM) Countywide EMS Medical Record Database 8
Fentanyl-Related Overdose Deaths January 2012-September 2016 56 30 5 11 16 2012 2013 2014 2015 2016 Of the 191 opioid-related overdose deaths between January 1, 2016 and September 24, 2016, 29% involved the drug fentanyl. In 2015, only 13% of opioidrelated overdose deaths involved fentanyl; the rate of overdose deaths involving fentanyl for the first nine months of 2016 alone already surpasses the rate for all of 2015. 9
Fentanyl-Related Overdose Death by Age Range January 2012-September 2016 25 31 24 29 7 0 1 1 0 0 0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90-99 Heroin-Related Overdose Deaths by Age Range January 2012-September 2016 132 118 87 69 30 0 9 1 1 0 0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90-99 Fentanyl-related deaths stay relatively steady from ages 20-59, while heroin-related deaths affect younger groups, with 20-29 year olds having the highest incidence. 10
Laypeople Overdose Reversal Attempts 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 158 2015 93 116 15% No 9-1-1 Call Reported 41 9-1-1 Call Reported 1 shot 2 shots 3 shots 4 shots 5 shots No Data 11 5 85% In 2016, ARCW collected self-reported data indicating 192 overdose reversal attempts. This number is significantly lower than those reported in 2015 but is considered an under-estimate. During 2016, the program was out of naloxone for approximately two months, new staff were being trained on data collection methods, and a new database was implemented. However, despite likely under-reporting, a similar proportion of individuals (12%) reported calling 9-1-1 at the time of the overdose. It is also important to note that based on additional survey questions, 6% reported taking the victim to the hospital in 2016. 11 Data Source: AIDS Resource Center of Wisconsin Needle Exchange Program Surveys
Location of Opioid-Related Overdose Death in Milwaukee County by Year January 2013-September 2016 2013 2014 2015 2016 LEGEND Death 12
Residence of Opioid-Related Overdose Victims Who Died in Milwaukee County January 2012 September 2016 Of the 967 opioid-related deaths in Milwaukee County, 64 (7%) had a residence outside of the county. Four of those residences are not in this map s range. LEGEND Residence 13
Percent of Opioid-Related Overdose Deaths Occurring at the Victims Residence in Milwaukee County January 2012-September 2016 From January 2012 through September 2016, 69% of people who experienced a fatal opioid-related overdose died in their place of residence. 14
Location of EMS Responses for Suspected Opioid-Related Overdose Based on Naloxone Administration 2014-2015 2014 2015 Data Source: Milwaukee County Office of Emergency Management s (OEM) Countywide EMS Medical Record Database 15
Density of EMS Response Location for Suspected Opioid-Related Overdose in Milwaukee County Based on Naloxone Administration January 2014-May 2016 Legend EMS Call Location Density 0 11 11 22 22 34 34 45 45 56 56 68 68 79 79 91 Low Density of Opioid-Related Deaths in Milwaukee County by Death Location January 2012-September Legend 2016 EMS Call Location 91 102 102 113 High Legend Opioid Death Density 0 3 Low 3 6 6 10 10 13 13 16 16 20 20 23 23 27 27 30 30 33 High Hospital with one or more opioid deaths Data Source: Milwaukee County Office of Emergency Management s (OEM) Countywide EMS Medical Record Database 16
EMS Transport Destination for Suspected Opioid-Related Overdose Victims Who Received Naloxone January 2014 May 2016 Transport Destination Number of calls Hospital Emergency Department 2314 (90%) Medical Examiner 140 (5.5%) Refused Transport 96 (3.7%) Other 1(<1%) Data Source: Milwaukee County Office of Emergency Management s (OEM) Countywide EMS Medical Record Database 17
Summary of Opioid-Related Overdose Deaths in Milwaukee County All Opioid Overdoses 2012-2016 2012 2013 2014 2015 2016 Total 967 144 181 220 231 191 Frequency Percent Frequency Percent Frequency Percent Frequency Percent Frequency Percent Frequency Percent Sex Male 602 62% 87 60% 102 56% 133 60% 149 65% 131 69% Female 364 38% 57 40% 79 44% 87 40% 81 35% 60 31% Age Range under 9 7 1% 0 0% 2 1% 0 0% 1 0% 4 2% 10-19 15 2% 2 1% 5 3% 1 0% 4 2% 3 2% 20-29 191 20% 23 16% 35 19% 50 23% 45 19% 38 20% 30-39 236 24% 36 25% 32 18% 48 22% 64 28% 56 29% 40-49 203 21% 30 21% 53 29% 44 20% 46 20% 30 16% 50-59 219 23% 42 29% 42 23% 49 22% 42 18% 44 23% 60-69 83 9% 9 6% 9 5% 24 11% 26 11% 15 8% 70-79 11 1% 2 1% 3 2% 3 1% 3 1% 0 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 1% Race/Ethnicity White 686 71% 95 66% 126 70% 157 71% 169 73% 139 73% Black 196 20% 33 23% 34 19% 46 21% 47 20% 36 19% Hispanic 64 7% 11 8% 16 9% 14 6% 9 4% 14 7% Other 18 2% 5 3% 5 3% 3 1% 5 2% 2 1% Drug Type* Heroin 447 46% 53 37% 69 38% 116 53% 110 48% 99 52% Oxycodone 305 32% 60 42% 64 35% 82 37% 59 26% 40 21% Methadone 132 14% 26 18% 26 14% 23 10% 39 17% 18 10% Morphine 159 16% 24 16% 37 20% 31 14% 48 21% 19 10% Fentanyl 118 12% 5 3% 11 6% 16 7% 30 13% 56 29% Not mutually exclusive **Heroin metabolizes to 6-monoacetylmorphine and is detectable in the blood for up to two hours in a living person. 6-monoacetylmorphine is then metabolized to morphine. When 6-monoacetylmorphine is found on a toxicology screen, the Medical Examiner can identify heroin as the cause of the overdose. However, if 6-monoacetylmorphine is not detected, morphine is identified as the cause of death. 18
Summary of EMS Responses for Suspected Opioid-Related Overdose Based on Naloxone Administration All Suspected Opioid Overdoses 2014-2015 2014 2015 Total 2193 1175 1018 Sex Frequency Percent Frequency Percent Frequency Percent Male 1326 60% 676 58% 650 64% Female 862 39% 495 42% 367 36% Age Range under 9 4 0% 1 0% 3 0% 10-19 53 2% 26 2% 27 3% 20-29 591 27% 276 23% 315 31% 30-39 450 21% 231 20% 219 22% 40-49 326 15% 172 15% 154 15% 50-59 359 16% 198 17% 161 16% 60-69 191 9% 111 9% 80 8% 70-79 116 5% 84 7% 32 3% 80-89 80 4% 59 5% 21 2% 90-99 23 1% 17 1% 6 1% Race/Ethnicity White 940 43% 483 41% 457 45% Black 338 15% 196 17% 142 14% Hispanic 76 3% 49 4% 27 3% Other 11 1% 7 1% 4 0% Unknown 828 38% 440 37% 388 38% Data Source: Milwaukee County Office of Emergency Management s (OEM) Countywide EMS Medical Record Database 19
Data Source: Milwaukee County EMS 9-1-1 Call Response with Naloxone Administration: January 1, 2014 May 1, 2016 EMS Responses for Suspected Opioid-Related Overdose in the North Shore Region of Milwaukee County January 2014-May 2016 EMS responses in this analysis were identified using EMS medical record data that was submitted to Milwaukee County s Office of Emergency Management (OEM) (N=102). Cases identified 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 (https://www.firstwatch.net/what-we-do/ems/) to identify overdoses in their region. First Watch reviews both key variables (e.g., primary/secondary impression and medication administration) and narratives for key words to identify potential opioid overdose victims. We compared our identified cases from the Milwaukee County OEM- EMS medical records database to those from the First Watch search and found that the two methods for identifying cases were equivilent, with the exception of one case. This case was likely not identified in the county data due to a documentation error. LEGEND Data Source: Milwaukee County Office of Emergency Management s (OEM) Countywide EMS Medical Record Database EMS Response Location 20