Identification of Specific Drugs and Drug Diversion in Drug Overdose Fatalities Svetla Slavova, PhD Sara LaMantia, MS Terry Bunn, PhD Tracey Corey, MD 2016 Safe States Annual Meeting April 13, 2016, Albuquerque, NM
Background 30 Age-adjusted Drug Overdose Mortality Rate 25 U.S. KY 24.7 Rate per 100,000 population 20 15 10 5 14.7 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple Cause of Death 1999-2014 on CDC WONDER Online Database, released 2015. Data are from the Multiple Cause of Death Files, 1999-2014, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Accessed at http://wonder.cdc.gov/mcd-icd10.html on Mar 30, 2016 1:51:15 PM
The purpose of the study was to use drug overdose fatality data from multiple data sources to: identify specific drugs involved in Kentucky resident drug overdose deaths; asses the concordance between toxicology reports and death certificate information; assess the extend of prescription drug diversion by linking death certificates and prescription drug monitoring program records; demonstrate the benefit of linking multi-source data for drug overdose fatality surveillance.
Methods/Approach: Population: Kentucky residents who died from drug overdose in Kentucky, 2013-2014 Data sources: Death certificates, 2013-2014 (Kentucky Office of Vital Statistics) Prescription drug monitoring program (PDMP) records, Kentucky All Schedule Prescription Electronic Reporting (KASPER), 2011-2014 (Kentucky Office of Inspector General) Toxicology records, 2013-2014 (Kentucky Office of Medical Examiners)
Methods/Approach: Death certificate data were analyzed according to Safe States Consensus Recommendations for Poisoning Surveillance.
Methods/Approach: Active prescriptions at the time of death by specific substance were identified based on National Drug Codes (NDCs). Available from http://www.fda.gov/drugs/informationondrugs/ucm142438.htm Daily dose morphine milligram equivalents (MMEs) were calculated at prescription and patient levels using CDC s National Center for Injury Prevention and Control conversion tables. Available from http://www.pdmpassist.org/pdf/conversion%20reference%20table.xlsx
Results: 1,971 drug overdose death certificates for Ky residents who died in Kentucky Gender: Males (61%) Drug Overdose by Intent Unintentional - 1,750 (89%) Suicide - 105 (5%) Undetermined intent - 116 (6%)
Rate (number of deaths per 100,000 residents) Drug Overdose Death Rates by Age Group 50 45 40 35 30 25 20 15 10 5 0 18-24 25-34 35-44 45-54 55-64 65+ Age-specific rates 15 36 46 44 27 5
Drug Overdose Death Rates by Gender and Age Group Rate (number of deaths per 100,000 residents) 60 50 40 30 20 10 0 18-24 25-34 35-44 45-54 55-64 65+ F 10 22 34 38 22 5 M 20 49 58 50 33 5
Drug Overdose Deaths by Place of Death 1400 Number of overdose deaths 1200 1000 800 600 400 200 0 ER/OUTPATIENT INPATIENT RESIDENCE OTHER Place of death 348 190 1078 355 Other e.g., 123 friend s place, 19 hotel or motel, 10- parking lot
Death certificate records linked with Ky PDMP prescription history: Of the 1,971 drug overdose death certificates : 219 ( 11%) were not matched to any Ky PDMP records 2 years prior to the death 56 (3%) seemed as false positive matches and were removed from further analysis 1,696 (86%) were successfully linked with Ky PDMP records and included in the following analysis
100% 90% Percentage of Ky resident drug overdose deaths by PDMP prescription history (any prescription) 86% 80% 70% 64% 60% 50% 45% 40% 30% 20% 10% 0% With Rx history within two years prior to the death With a Rx filled within 6 months before the death 2013-2014 With an active Rx on the day of the death
Percentage of Ky resident deaths with a prescription filled within the last 6 months before the death 60.0% 56.9% 50.0% 40.0% 40.2% 30.0% 20.0% 10.0% 0.0% 3.0% 2.2% Opioids Benzodiazepines Muscle Relaxant Stimulant 2013-2014
Concordance between contributing drugs listed on the death certificate and active prescriptions in the PDMP database Number and percentage of drug overdose death certificates mentioning the drug as contributing to the death Number and percentage of deaths with active prescription for the contributing drug ALPRAZOLAM 339 (17.2%) 112 (33%) HYDROCODONE 317 (16.1%) 152 (48%) OXYCODONE 271 (13.8%) 105 (38.5%) FENTANYL 151 (7.7%) 20 (13.2%) METHADONE 118 (6%) 17 (14.4%) CLONAZEPAM 116 (5.9%) 59 (50.9%) DIAZEPAM 110 (5.6%) 30 (27.3%) BUPRENORPHINE 49 (2.5%) <5 TRAMADOL 36 (1.8%) 18 (50%)
Specific drugs contributing to the overdose deaths vs. drugs present at the time of the death Percentage of drug overdose death certificates mentioning the drug as contributing to the death Percentage of deaths with positive toxicology ALPRAZOLAM 17.20% 35.50% HYDROCODONE 16.10% 30.60% HEROIN 20.80% 28.60% OXYCODONE 13.80% 27.20% DIAZEPAM 5.60% 23.10% CLONAZEPAM 5.90% 21.30% COCAINE 7.30% 11.70% FENTANYL 7.70% 10.70% METHADONE 6% 10.20% BUPRENORPHINE 2.50% 8.20% TRAMADOL 1.80% 3.80%
Percentage of overdose deaths with positive toxicology reports that listed the drug(s) on the death certificates Alprazolam Amphetamine Buprenorphine Clonazepam Cocaine Diazepam Fentanyl Gabapentin Heroin Hydrocodone Hydromorphone* Methadone Methamphetamine Morphine* Oxycodone Oxymorphone* Tramadol 4.1% 13.3% 15.3% 14.1% 30.0% 27.3% 23.8% 27.7% 48.2% 61.6% 52.1% 57.6% 60.4% 49.2% 47.9% 71.4% 71.3% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0%
Were there active prescriptions for the drugs showing on the toxicology reports? Drug overdose deaths with an active prescription on the day of the death as a percentage of the overdose deaths with positive toxicology reports Alprazolam Buprenorphine Clonazepam Diazepam Fentanyl Hydrocodone Hydromorphone* Methadone Morphine* Oxycodone Oxymorphone* Tramadol 6.3% 0.8% 4.1% 2.6% 14.6% 13.2% 22.2% 32.4% 40.0% 41.7% 36.2% 37.0% 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0% 45.0%
Implications: The case of Fentanyl Fentanyl Deaths 2013 2014Total Drug overdose deaths listing fentanyl on the death certificate 37 114 151 Percentage of drug overdose death certificates mentioning the drug as contributing to the death Percentage of deaths with positive toxicology ALPRAZOLAM 17.20% 35.50% HYDROCODONE 16.10% 30.60% HEROIN 20.80% 28.60% OXYCODONE 13.80% 27.20% DIAZEPAM 5.60% 23.10% CLONAZEPAM 5.90% 21.30% COCAINE 7.30% 11.70% FENTANYL 7.70% 10.70% METHADONE 6% 10.20% BUPRENORPHINE 2.50% 8.20% TRAMADOL 1.80% 3.80% Drug overdose deaths with positive tox for fentanyl 56 150 206 Drug overdose deaths with active Rx for fentanyl as of the day of the death 14 19 33
Fentanyl an other drugs: 12% (18 of the 151 fentanyl-related deaths) involved heroin 22% listed heroin or morphine 16% involved oxycodone 10% involved hydrocodone 52% had an opioid prescription in the last 6 month (only 36% of the heroin decedents had an opioid prescription in the last 6 mo) 22% had at least one prescription for opioid with a daily dose of 100 morphine milligram equivalent or more 15% had a fentanyl prescription during the last 6 months Geographically the counties with the highest heroin overdose death rates had the highest fentanyl overdose death rates.
Conclusions: Kentucky public health officials, regulatory boards, and law enforcement need multiple sources of drug-related data in making informed data-driven decisions to address controlled substance abuse and diversion at state and local levels. Integrated multi-source drug overdose fatality surveillance allows better identification of drug diversion and harmful prescribing practices, informs targeted state and local prescriber education, law enforcement, policy and program evaluation, and surveillance quality improvement.
Svetla Slavova, ssslav2@email.uky.edu