A Public Health Response to an Epidemic of Fatal Drug Overdoses

A Public Health Response to an Epidemic of Fatal Drug Overdoses in North Carolina Catherine (Kay) Sanford, MSPH Injury and Violence Prevention Branch Division of Public Health, NC-DHHS kay.sanford@ncmail.net 919.707.5434 NC DHHS Injury and Violence Prevention Branch, 10/27/2005 1 NC‟s Public Health Steps 1. CDC-NCIPC Injury Indicator Report 2. EIS Investigation – Fatal Poisonings in NC 3. Task Force on Unintentional Drug Overdoses 4. MMWR on Unintentional Drug Overdoses in 11 states 5. Task Force Recommendations 6. NC-DOJ/DHHS Leadership Committee on Drug Overdoses 7. Year 1: Surveillance and PMP Legislation NC DHHS Injury and Violence Prevention Branch, 10/27/2005 2 1. CDC-NCIPC Injury Indicator Report 1. NC Division of Public Health Injury and Violence Prevention Branch funded through CDC‟s “Core Capacity” program in 2000. 2. In 2001-2002, NC Injury Program participated in first national Injury Indicator Report; approx. 20 states, using 1999 data. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 3 Age-Adjusted Mortality Rates of Selected Injuries, United States: 1991-2000 Mortality Rates/100,000 18 16 14 12 10 8 6 4 2 0 19 91 19 92 19 93 19 94 19 95 19 96 19 97 19 98 19 99 20 00 Falls Fire/Burns Firearms MVC Poisons NC DHHS Injury and Violence Prevention Branch, 10/27/2005 4 Definition of Poisoning • Damaging physiologic effects from exposure to – pharmaceuticals (prescribed and OTC) – illicit drugs (e.g., cocaine, heroin) – chemicals (e.g., pesticides) – heavy metals (e.g., mercury) – gases/vapors (e.g., carbon monoxide) – household substances (e.g, bleach, ammonia) NC DHHS Injury and Violence Prevention Branch, 10/27/2005 5 Accidental Drug Overdose - International Classification of Disease (ICD) Definition • Unintentional (Accidental) Drug Overdose – Inaccurate prescription or administration of a drug/substance – Inappropriate consumption of a drug/substance NC DHHS Injury and Violence Prevention Branch, 10/27/2005 6 Adverse Effect from Drug- International Classification of Disease (ICD) Definition • Adverse Effect(s) from a Drug – Appropriate prescription/administration of drug with the patient experiencing an adverse physiologic reaction to the drug/substance. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 7 Comparing NC injury trends to that of the nation. Intentional and Unintentional Poisoning Crude Death Rates in the US and NC: 1997-2001 9 8 7 6 5 4 3 2 1 0 Crude Rates / 100,000 6.61 4.77 6.81 5.51 7.24 7.35 7.8 7.73 6.96 5.44 US NC 1997 WISQARS:www.cdc.gov/ncipc/ 1-2004 1998 1999 2000 2001 8 NC DHHS Injury and Violence Prevention Branch, 10/27/2005 NC Resident Deaths Due to Poisoning by Manner/Intent: 1997 – 2001 700 638 600 Number of Deaths 560 500 440 437 367 279 228 126 19 1 230 149 141 169 186 400 300 200 100 0 380 406 Unintentional Suicide Homicide Undetermined Total 24 3 19 2 22 3 11 4 1997 1998 1999 2000 2001 9 NC DHHS Injury and Violence Prevention Branch, 10/27/2005 2. EIS Investigation – ? Epidemic of Fatal Poisonings in North Carolina 1. Mortality data showed clear evidence that increase in deaths was due to unintentional poisonings. 2. NC State Health Director requested an EIS investigation from CDC 3. June-July 2002: Review of 1,096 Medical Examiner cases in 3 weeks 4. Confirmation on Indicator Report findings NC DHHS Injury and Violence Prevention Branch, 10/27/2005 10 Case Definition: Underlying cause of death from Medical Examiner – Underlying cause was drug-related based on impression of ME on investigation report, and review by pathologists and toxicologists at OCME: autopsy, toxicology report, review of clinical and historical information. – M. E. concluded manner of death was accidental NC DHHS Injury and Violence Prevention Branch, 10/27/2005 11 Case Definition for Reviewing Medical Examiner Cases of Accidental Drug Overdose Deaths • Initial Selection: all NC residents dying in NC between 1997 and 2001, inclusive, with an underlying cause of death due to unintentional drug-related poisoning (E850E858; X40-X44) with a death certificate on file at the NC State Center for Health Statistics. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 12 ME Chart Abstraction 1997 1998 1999 2000 2001 97-01 187 191 234 318 390 1320 157 155 190 278 316 1096 84.0 81.2 81.2 87.4 81.0 83.0 Vital Stats ME Abstraction % of VS NC DHHS Injury and Violence Prevention Branch, 10/27/2005 13 Deaths from Unintentional Drug Overdoses from NC ME Data (n=1,096) by Age and Sex : 1997-2001 250 200 Number Died 150 100 50 0 2 1 17 7 76 55 103 154 156 111 Males Females 40 69 21 23 38 73 53 32 19 10 16 20 0-14 15- 20- 25- 30- 35- 40- 45- 50- 55- 60+ 19 24 29 34 39 44 49 54 59 NC DHHS Injury and Violence Prevention Branch, 10/27/2005 14 Unintentional Drug Deaths by Race from Abstracted ME Records (N=1096) in NC: 1997-2001 350 300 Number Died 250 200 150 100 50 0 41 28 42 53 53 116 148 127 225 263 1997 1998 1999 Not White White 2000 2001 NC DHHS Injury and Violence Prevention Branch, 10/27/2005 15 Unintentional Drug Deaths by Sex from Abstracted ME Records (N=1096) in NC: 1997-2001 Females: N=347 31.7% Males: N=749 68.3% NC DHHS Injury and Violence Prevention Branch, 10/27/2005 16 Unintentional Drug Deaths by Sex and Year from Abstracted ME Records (N=1096) in NC: 1997-2001 250 200 193 198 Number Died 150 119 111 128 118 85 62 100 50 0 1997 1998 1999 38 44 2000 2001 Males: 66% increase Females: 210% increase 17 NC DHHS Injury and Violence Prevention Branch, 10/27/2005 NC DHHS Injury and Violence Prevention Branch, 10/27/2005 18 Treatment Provided Prior to Deaths from Unintentional Drug Overdoses from Medical Examiner Data in North Carolina: 1997-2001 Hos pital/die d 7% Rx @ ED/die d 17% Trans porte d/ DOA 9% Rx @ Sce ne /die d 8% Sce ne /de ad 59% DOA = dead on arrival ED = emergency department Rx = treatment (1,096 ME cases) NC DHHS Injury and Violence Prevention Branch, 10/27/2005 19 Unintentional Drug Deaths by Past Medical History from Abstracted ME Records (N=1096) in NC: 1997-2001 Drug Abuse Alcohol Abuse/Alcoholism Chronic Pain Mental Health 53.8% 23.8% 20.1% 20.4% NC DHHS Injury and Violence Prevention Branch, 10/27/2005 20 Decedents’ Source of Drugs from NC Medical Examiner Records by Sex : 1997-2001 60 Percent of Deaths 50 40 30 20 10 0 48 28 33 22 2 Dr ug s De ce de nt O th er 33 34 Male Female 2 1 Pr es cr ip tio n 2 Un kn ow So ur ce n Pr es cr ip tio ns Pr es cr ip tio ns St re et Ill eg al an d NC DHHS Injury and Violence Prevention Branch, 10/27/2005 21 Deaths Resulting From a Single Drug by Type and Sex, NC Medical Examiner Records: 1997-2001 30 27 26 25 20 15 10 5 0 ne ai c Co in ro He ha et M e on d e in ph or M co xy O e on d yl an t en F 24 19 Percent of Deaths 22 Male Female 8 7 7 5 4 5 7 NC DHHS Injury and Violence Prevention Branch, 10/27/2005 22 Unintentional Deaths from a Single Drug: Illicit Drugs, North Carolina, 1997-2001 1997 n=117 Cocaine 52 (44%) Heroin 23 (20%) Morphine 9 (8%) 1998 n=109 Heroin 32 (29%) Cocaine 31 (28%) Fentanyl 7 (6%) 1999 n=131 Cocaine 44 (34%) Heroin 30 (23%) 2000 n=197 2001 n=226 „97-‟01 n=780 Methadone Methadone 56 (28%) 58 (26%) Methadone Methadone 7 7 (6%) (6%) Fentanyl Morphine 6 7 (6%) (5%) Propoxyphene Propoxyphene 5 (4%) 2 (2%) Cocaine 48 (24%) Methadone Heroin 19 (15%) 31 (16%) Morphine Morphine 5 (4%) 15 (8%) Fentanyl Oxycodone 4 (3%) 14 (7%) Hydrocodone Fentanyl 4 (3%) 11 (6%) Cocaine 221 (28%) Cocaine Heroin 46 (20%) 147 (19%) Methadone Heroin 31 (14%) 147 (19%) Oxycodone Morphine 19 (8%) 53 ( 7%) Morphine Fentanyl 17 (8%) 42 (5%) Fentanyl Oxycodone 14 (6%) 38 (5%) NC DHHS Injury and Violence Prevention Branch, 10/27/2005 23 Unintentional Deaths from a Single Drug: Licit Drugs North Carolina, 1997-2001 „97-‟01 n=780 Cocaine 221 (28%) Heroin 147 (19%) Methadone 147 (19%) 1997 n=117 Cocaine 52 (44%) Heroin 23 (20%) Morphine 9 (8%) Methadone 7 (6%) 1998 n=109 Heroin 32 (29%) Cocaine 31 (28%) Fentanyl 7 (6%) Methadone 7 (6%) 1999 n=131 Cocaine 44 (34%) Heroin 30 (23%) 2000 n=197 2001 n=226 Cocaine 46 (20%) Heroin 31 (14%) Oxycodone 19 (8%) Methadone Methadone 56 (28%) 58 (26%) Fentanyl 6 (5%) Propoxyphene Morphine 7 (6%) Propoxyphene 5 (4%) 2 (2%) Cocaine 48 (24%) Methadone Heroin 19 (15%) 31 (16%) Morphine Morphine 5 (4%) 15 (8%) Oxycodone Fentanyl (7%) 4 (3%) 14 Hydrocodone Fentanyl 4 (3%) 11 (6%) Morphine 17 (8%) Fentanyl 14 (6%) Morphine 53 ( 7%) Fentanyl 42 (5%) Oxycodone 38 (5%) NC DHHS Injury and Violence Prevention Branch, 10/27/2005 24 Unintentional Deaths from Multiple Drugs: North Carolina, 1997-2001 1997 Alcohol 17 (43%) Cocaine 14 (35%) Heroin 10 (25%) 1998 1999 Alcohol 21 (36%) Cocaine 14 (24%) Methadone 10 (17%) Oxycodone 6 (10%) 2000 Alcohol 26 (32%) Oxycodone 21 (26%) Cocaine 19 (23%) 2001 97-01 Alcohol 99 (31%) Cocaine 90 (28%) Heroin 58 (18%) Oxycodone 52 (16%) Methadone 51 (16%) Hydrocodone Cocaine 18 (39%) Heroin 18 (39%) Alcohol 14 (30%) Hydrocodone Morphine 8 (20%) 8 (17%) Hydrocodone Morphine 3 (8%) 5 (11%) Alprazolam 3 (8%) Alprazolam 5 (11%) Cocaine 25 (28%) Oxycodone 22 (24%) Methadone 22 (24%) Hydrocodone Alcohol 12 (15%) 21 (23%) Hydrocodone Methadone Hydrocodone 6 (10%) 11 (14%) 19 (21%) Alprazolam Alprazolam Heroin 6 (10%) 11 (14%) 13 (14%) 50 (16%) No. deaths = 316 NC DHHS Injury and Violence Prevention Branch, 10/27/2005 25 Deaths Resulting From a Single Drug (n=780): Change from 1997 to 2001 1997 2001 Number Change All Poisoning deaths Methadone % change from 97 to 01 93% 729% % of overall increase ----46.7% 117 7 226 58 109 51 All Rx Narcotics 32 128 96 300% 88.1% NC DHHS Injury and Violence Prevention Branch, 10/27/2005 26 Why Methadone? • Relatively effective AND cheap analgesic; • Reluctance of some MD‟s to prescribe other synthetic opioids (e.g., oxycodone); • Relatively few side effects; no euphoria The Catch 22 • Very long half-life; • Idiosyncratic metabolism; requires careful follow-up first couple of weeks. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 27 The Source of the Methadone? • Probably not the OTP clinics-diversion not thought to be prevalent in NC; • Likely diversion from prescriptions for abuse - recreation or to compensate for no heroin; • Likely misuse for pain management. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 28 3. Creation of Task Force on Unintentional Drug Overdoses • Created by Secretary of NC-DHHS, Nov. 2002 • Mission: study epidemic and develop recommendations to identify, reduce and ultimately prevent unintentional deaths from the use of illicit and licit drugs. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 29 North Carolina Task Force to Prevent Deaths from Unintentional Drug Overdoses Medical Practice Toxicology Pharmacy Co-chaired by State Epidemiologist and Ass‟t Director SBI Law and Criminal Justice State and Federal Law Enforcement Public Health Mental Health Medical Examiners Substance Abuse Services Epidemiologic Surveillance Injury Prevention Specialists NC DHHS Injury and Violence Prevention Branch, 10/27/2005 30 Results of Task Force to Prevent Deaths from Unintentional Drug Overdoses • Met for 15 months. • Report sent to DHHS and DOJ, April 2004. • Findings described an increasing epidemic of deaths from unintentional drug overdoses in NC. • 48 Recommendations to prevent or mitigate deaths: – State infrastructure to focus on prevention; surveillance, law enforcement, legislation, education for professionals, education for public, and clinical intervention. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 31 Three Dimensional Haddon Matrix Pre-event Other identified criteria Phases Feasibility Event Preferences Stigmatization Equity Post-event Freedom Cost Host Agent/ vehicle Effectiveness Physical environment Social environment Decision Criteria Factors NC DHHS Injury and Violence Prevention Branch, 10/27/2005 Adapted from Runyan, CW. Injury Prevention, 1998(4), 302-307 32 4. MMWR on Unintentional Drug Overdoses in 11 states 1. Concomitant research within the state and with other states on increases in unintentional drugrelated deaths. Findings continued to support increasing deaths. Published MMWR: March 26, 2004 (vol.53#11). 33 2. 3. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 5. Task Force Recommendations • Submitted to Secretary of NC-DHHS and Attorney General of NC-DOJ, April 2004. • 48 recommendations: no defeats; never more than one “no” vote; primary objections from pharmacy representatives. • Harm Reduction could not be included due to funding constraints. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 34 NC Drug Task Force Recommendations 1. LEADERSHIP recommendations create a joint DHHS and DOJ leadership structure for oversight of all surveillance, intervention and enforcement activities related to preventing unintentional drug overdoses. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 35 NC Drug Task Force Recommendations 2. SURVEILLANCE recommendations compile and monitor data relevant to unintentional overdoses that are provided to the DHHS/DOJ Leadership Committee at least four times a year. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 36 NC Drug Task Force Recommendations 3. LAW ENFORCEMENT recommendations provide infrastructure to prevent illegal distribution and use of controlled medications. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 37 NC Drug Task Force Recommendations 4. LEGISLATIVE INITIATIVE recommendations create requirements and regulations necessary to implement surveillance activities, create fines to help finance the system and improve access to treatment services. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 38 NC Drug Task Force Recommendations 5. EDUCATIONAL INTERVENTIONS – GENERAL PUBLIC recommendations to raise public awareness about the magnitude, risks and signs of unintentional overdose, preventive behaviors and precautions, and available emergency treatment and law enforcement resources. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 39 NC Drug Task Force Recommendations 6. EDUCATIONAL INTERVENTIONS – PROFESSIONALS recommendations to raise professional awareness about the magnitude, risks and signs of unintentional overdose and create practice guidelines and educational and credentialling requirements for prevention, treatment and enforcement activities. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 40 NC Drug Task Force Recommendations 7. CLINICAL INTERVENTIONS Recommendations to expand forgery notification systems, improve emergency provider preparedness, increase resources for recovering addicts, and broaden the evidence base for implementing new, effective out-patient and in-patient treatment programs. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 41 6. NC-DOJ/DHHS Leadership Committee on Drug Overdoses • Recommendations premised on a state infra-structure to focus on implementing recommendations. • MOU required between NC-DOJ and DHHS, and signed August 2004. • Committee convened October 2004; meets quarterly. • Representation from Law Enforcement; Mental Health, Public Health, Clinical Practice, Pharmacy Practice with IVPB facilitator. • Focus for 2005: surveillance and enabling legislation for a controlled substance reporting system NC DHHS Injury and Violence Prevention Branch, 10/27/2005 42 7. Year 1 Leadership Committee Priorities: Surveillance and PMP Legislation • Injury surveillance from death certificates and hospital discharge data on drug-related events; on-going. New data available from Poison Control Center and Emergency Department databases. • Enabling legislation required for monitoring prescriptions of controlled substances. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 43 SURVEILLANCE NC Resident Deaths Due to Poisoning by Manner/Intent: 1997 – 2004 1000 900 800 700 600 500 400 300 200 100 0 868 722 638 560 380 228 126 406 230 149 440 367 279 141 169 186 155 151 184 437 547 690 729 Number of Deaths Unintentional Suicide Homicide Undetermined Total 24 25 22 20 19 19 11 3 2 3 4 2 1 0 1997 1998 1999 2000 2001 2002 2003 2004 NC DHHS Injury and Violence Prevention Branch, 10/27/2005 44 LEGISLATION Naming the PMP • A controlled substance reporting (CSR) System is a system into which prescription data for designated schedules of controlled substances are reported by dispensers to a central location where the information is entered into an electronic database. • North Carolina would report Schedules II-V prescriptions dispensed on an out-patient basis. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 45 LEGISLATION Being Politically Savvy • • • • • • Established leadership authority. Reviewed the history of past failures. Identified stakeholders. Identified credible spokespersons. Identified the opposition. Identified House and Senate sponsors. 46 NC DHHS Injury and Violence Prevention Branch, 10/27/2005 LEGISLATION What did we do differently? • Re-cast the CSR System as a public health initiative, but … • Agreed to have legislation submitted as a revision of the Controlled Substances Law. • Worked through the NC-DHHS legislative liaison and legal counsel in DPH. • Included legislation as a special amendment to the state budget. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 47 Next Steps • Have legislative rules adopted from the Mental Health Commission. • Apply for implementation funding from national sources. • Establish a CSR System Advisory Board. • Design the actual database. • Continue the collaboration between DMH, DPH and DOJ in North Carolina. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 48