Download - The Grand Unifying Theory of Poisoning/Overdose Surveillance A Collaborative Effort June 9, 2013
The Grand Unifying Theory of Poisoning/Overdose
SurveillanceA Collaborative Effort
June 9, 2013
Motor Vehicle Traffic, Poisoning, and Drug Poisoning Death Rates
US 1980-2010
1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 20100
5
10
15
20
25
Motor Vehicle Traffic
Poisoning
Drug Poisoning (Overdose)
Year
De
ath
s p
er
10
0,0
00
po
pu
lati
on
NCHS Data Brief, December, 2011, Updated with 2009 and 2010 mortality data
Opioid Analgesics:The National Picture
• Fastest growing drug problem in United States• Enough prescription painkillers prescribed in
2010 to medicate every American adult around-the-clock for a month
• ~12 million Americans report misuse of opioid analgesics within past year (2010) >16,000 overdose deaths from opioid analgesics (2010)
• Considered an “epidemic”
Background & History
Background & History• Safe States Poisoning Workgroup- 2008• Safe States formation of Injury Surveillance Workgroup
(ISW-7)• Publication of ISW7- May 2012• CDC/Safe States/CSTE conferences 2012• CSTE Drug Overdose-
– Willing and wanting to test ISW7 indicators– Providing organizational base for effort
• SQI Year 2 focus on poisoning• Real partnership with Safe States – liaison/driving force
• Scott Proescholdbell
Why CSTE Overdose subcommittee choose this project
• Increased attention by States to report and track drug overdose
• Lack of consistent definitions and indicator • Variations across States and local level • Recognizing that lack of detail on death
certificates underestimates deaths for specific drugs
• Concern about shifting from opioid analgesics to heroin → accurate classification of opiates critical
Timeline 2012-2013
Timeline• August- Organizational Call• Creation of Poisoning Surveillance Workgroup• Fall 2012- Creation of tables shells and Levels I-IV
(basic to complex)• Winter- submission of data by volunteer states and
proposal to present data• Spring- Data results & write up of methods and
process for Special Emphasis Report• Spring- April CDC mtg on poisoning for Core states
Next Steps
Next Steps• June- Presentations (Safe States & CSTE)• July- development of Special Emphasis
Report and pilot testing• Transition from mortality to morbidity (SQI
protocol)• Additional testing of codes, development of
potential indicators and position statements
Introduction to Mortality Surveillance: Levels 1-3
Daniella Bradley O’Brien
Outline• Definition of terms
– What is a drug poisoning (overdose) death?– What is an ICD Code?
• What ICD-10 codes are used?• Intent• Underlying/Multiple Cause of Death
• Surveillance levels 1-4• How to surveil drug poisoning deaths
Definition of Terms
International Classification of Diseases-10th classification (ICD-10)
• Standard diagnostic tool for epidemiology, health management and clinical purposes
• Monitors the incidence and prevalence of diseases and other health problems
• Defines the universe of diseases, disorders, injuries and other related health conditions. It allows for:– sharing and comparing health information between hospitals, regions,
settings and countries; and– data comparisons in the same location across different time periods.
• Does not always identify specific drugs causing death
External Cause of Injury Mortality Matrix
External Cause of Injury Mortality Matrix
Mechanism of Death
Intent of Death (Based ICD-10)
Unintentional Suicide Homicide UndeterminedLegal
Intervention/war
Poisoning X40-X49 X60-X69 X85-X90,U01.6-.7 Y10-Y19 Y35.2
Drug Type Unintentional Suicide Undetermined Homicide
Nonopioid analgesics, antipyretics and anti-rheumatics
X40 X60 Y10
X85
Sedative-hypnotic, psychotropic
X41 X61 Y11
Narcotics and psychodysleptics (hallucinogens), NOS
X42 X62 Y12
Other drugs acting on CNS X43 X63 Y13
Other and unspecified drugs
X44 X64 Y14
Underlying ICD-10 Drug Poisoning Codes
Medical Examiner/Coroner: Determining cause and manner of death
Death scene
investigationAutopsy Toxicology
Determination of cause and
manner of death
Context• Paraphernalia• Pill bottles• Witness
accounts
Physical findings• Heart muscle
(e.g. damaged by cocaine use)
• Asthma
Drugs• Active (capable of
causing death)• Synergistic • Contributing• Present, not active
CAUSE OF DEATH (See instructions and examples) Approximate interval: Onset to death32. PART I. Enter the chain of events - - diseases, injuries, or complications - - that directly caused the death. DO NOT enter
terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
IMMEDIATE CAUSE (Final disease or condition resulting in death) a. Acute intoxication
Sequentially list conditions, if any, leading to the cause listed on line a. Enter the UNDERLYING CAUSE (disease or injury that initiated the events resulting in death) LAST
Due to (or as a consequence of):
Due to the combined effects of b. Heroin and Oxycodone Due to (or as a consequence of):
c.
Due to (or as a consequence of):
d.
PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in Part I.
Asthma
33. WAS AN AUTOPSY PERFORMED? Yes No
34. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE THE CAUSE OF DEATH? Yes No
35. DID TOBACCO USE CONTRIBUTE TO DEATH?
Yes Probably No Unknown
36. IF FEMALE: Not pregnant within past year Pregnant at time of death Not pregnant but pregnant within 42 days of death Not pregnant but pregnant 43 days to 1 year before death Unknown if pregnant within the past year
29. MANNER OF DEATH Natural Pending Accident Investigation Suicide Could not be Homicide Determined
38. DATE OF INJURY(Mo/Day/Yr)(Spell Month)
39. TIME OF INJURY 40. PLACE OF INJURY (e.g., Decedent’s home, construction site, restaurant, wooded area)
41. INJURY AT WORK?
Yes No
42. LOCATION OF INJURY: State: City or Town: Street & Number: Apartment No. Zip Code:
43. DESCRIBE HOW INJURY OCCURRED
Acute and Chronic Substance Abuse44. IF TRANSPORTATION INJURY, SPECIFY Driver/Operator Passenger Pedestrian Other (Specify)
To B
e C
ompl
eted
By:
ME
DIC
AL
CE
RT
IFIE
R
X
Part IIOther significant conditions contributing to death
Part I Lines a-d Causes of death are entered sequentially starting with immediate cause and ending with the underlying cause.
How injury occurredGenerally determines external cause of death.
Manner
Death Certificate Literals
• “Literals” are the exact text entered on the death certificate
• Specialized software reads the literals and automatically codes both underlying and multiple cause of death
Exact words from Part I, Part II, manner and how the injury occurred
Mortality Medical Data
System
Automated coding of causes of death
Death Certificate
Cause of death
Part 1a. _Acute Intoxicationb. Due to combined___
effects of heroin and oxycodone. _________________
d. _________________
Part 2 :Asthma
Manner: AccidentDescribe how injury occurred:Acute and Chronic Substance Abuse
Cause of death by ICD-10 codes
UCOD: X42MCOD: X42, T40.1, T40.2,
CSTE Validation of ISW-7: Methods
• 4 levels– Level 1: Basic– Level 2: Multiple Cause– Level 3: Cross-Check– Level 4: Multi-stage
• Year 2010• Residents of each
state that died in state• 11 states/jurisdictions
Drug Poisoning Mortality Surveillance “Levels 1-4”Level 4:
Multi-Stage
Toxicology and
Literals
Level 1: Basic
Underlying cause of death file
Level 1: Basic Analysis ObjectiveLevel 4:
Multi-Stage
Toxicology and
Literals
Level 1: Underlying cause
with associated demograp
hics
Level 1: Basic Analysis
*Note: To obtain Death Certificate contact your city/state’s Office of Vital Statistics or agency equivalent responsible for the reporting, processing, and analyzing all vital events (births, deaths, etc.)
Required Resource: Death Certificate*
Obtain Underlying Codes
Use Underlying Codes:X40-X44, X60-X64, X85, Y10-Y14, Y40-Y59,
[F11-F16] (.0), F19.0
Tabulate results for Level 1
Level 1: Basic AnalysisDemographics X40 X41 X42 X43 X44
X40-X44 Total
N % N % N % N % N % N %Total 87 100% 87 100% Gender Male 54 62% 54 62% Female 33 38% 33 38% Race/Ethnicity
Black Non-Hispanic 27 31% 27 31% White Non-Hispanic 29 33% 29 33% Hispanic 28 32% 28 32% Asian/Pacific Islander 1 1% 1 1%
American Indian/ Alaskan Native 1 1% 1 1% All Other 1 1% 1 1% Age Group 0-14 1 1% 1 1% 15-24 10 11% 10 11% 25-34 15 17% 15 17% 35-44 20 23% 20 23% 45-54 18 21% 18 21% 55-64 10 11% 10 11% 65-84 6 7% 6 7% 85+ 4 5% 4 5%
Level 1: Summary• Report on poisoning by intent
• Provide demographic profile of the decedents– Age– Gender– Race/Ethnicity– Residential information available but not
collected/tested as part of CSTE validation of ISW-7
Level 2: Multiple Cause Objective Level 4:
Multi-Stage
Toxicology and
Literals
Level 1: Underlying cause
with associated demograp
hics
T-codes
• Are multiple cause codes
• Identify specific drug or substance
• For poisoning and toxic effects in ICD-10 these are T36-T65
Multiple Cause T-Codes by Drug TypeExample drugs Drug category ICD-10 code
“Morphine”“Oxycodone”“Hydrocodone”
Natural and semi-synthetic opioid analgesics (aka “Other opioids”) T40.2
“Methadone” Methadone T40.3
“Fentanyl”“Propoxyphene”“Meperidine”
Synthetic opioid analgesics, excluding methadone(aka “Other synthetic narcotics”)
T40.4
“Opiates”“Opioid”“Narcotics”
Other and unspecified narcotics T40.6
“Cocaine” Cocaine T40.5
“Heroin” Heroin T40.1
“Alprazolam” Benzodiazepines T42.4
“Methamphetamine” Methamphetamine T43.6
“Drugs”“Polypharmacy” Other and unspecified drug(s) T50.9
Opioid analgesics
Level 2: Multiple Cause AnalysisRequired Resource: Death Certificate*
Obtain Multiple Cause Codes:1. Underlying Cause Codes2. Contributing Cause Codes
Tabulate results for Level 2
Use Multiple Cause Codes:X40-X44, X60-X64, X85, Y10-Y14, Y40-Y59,
[F11-F16] (.0), F19.0, T36-T50.9
Level 2: Multiple Cause CodesX40 X41 X42 X43 X44
Total X40-X44
N % N % N % N % N % N %
T42.4:Benzodiazepines 10 9% 10 9%
T40.1: Heroin 20 18% 20 18%T40.2: Other opioids (Incl:Codeine, Oxycodone,Morphine) 35 32% 35 32%
T40.3 Methadone 10 9% 10 9%
T40.4:Other synthetic narcotics(Incl:Pethidine) 1 1% 1 1%
T40.5: Cocaine 15 14% 15 14%T40.6:Other and unspecified narcotics 7 6% 7 6%T50.9: Other and unspecified drugs, medicaments and biological substances 10 9% 10 9%T50.9: Other and unspecified drugs, medicaments and biological substances **Only T50.9 listed, no other T-codes (between T30.0 and T50.8) listed** 2 2% 2 2%
* This row includes any mention of T50.9, where it can be listed alone or as one of several T-codes listed.
** This row includes only occurrences where T50.9 is the only T-code listed (between T36.0 and T-50.8). This is a subset of the Any Mention of T50.9 row.
Level 2: Summary
• Report major categories of drug types by intent
Level 3: Cross-Check ObjectiveLevel 4:
Multi-StageToxicology and
Literals
Level 3: Literal text from death certificate
Level 2:
Drug Specificity (T-Codes)
Level 1: Underlying cause with associated
demographics
Uses of literal text
• Identifying specific substances in “other specified” ICD-10 drug categories
• Monitoring increases in deaths associated with drug substances not specifically identified in ICD-10
• Potential for use as a sentinel surveillance system for new drugs associated with deaths
Level 3: Cross-Check AnalysisRequired Resource: Death Certificate*
Obtain Multiple Cause Codes:1.Underlying Cause Codes2. Contributing Cause Codes
Tabulate results for Level 3
Cross-check Death Certificate Literals against Multiple Cause Codes
Use Multiple Cause Codes:X40-X44, X60-X64, X85, Y10-Y14, Y40-Y59, [F11-F16] (.0),
F19.0, T40.1,T40.2,T40.3,T40.4,T40.6,T43.6,T50.9
Level 3: Cross-Check Analysis
Part 1a Part 1b Part 1c Part 2Underlying Code
Multiple/ Contributing Codes
How Injury Occurred
Acute Oxycodone Intoxication
X42 T40.2 Ingested Medication
Level 3 Summary• Specificity of literals
– ex: T40.2 Oxycodone/Hydrocodone/Morphine
• Determine how literals are coded in your state/jurisdiction
Introduction to Level 4:Multistage Analysis
Denise Paone
Drug overdose deaths – 4 “Levels”Level 4:
Toxicology and Literals
Level 3: Literal text from death certificate
Level 2:
Drug Specificity (T-Codes)
Level 1: Underlying
cause of death file
Definitions/Terms
• Toxicology– Collected and analyzed as part of death
investigation– Not always available
Level 4: Multistage AnalysisObjective & Methods
• Objective:– Compare toxicology results using ME
findings, with ICD-10 codes and literals found on death certificates
• Methods:– Restricted T-Codes to cases involving
opioids/unspecified
Level 4: MultistageRequired Resource: Death Certificate* + Medical
Examiner/Coroner files containing Toxicology Report
Comparison of Death Certificate Multiple Cause Codes with confirmed Toxicology data
Comparison of Death Certificate Literals with confirmed Toxicology data
Comparison of Death Certificate Multiple Cause Codes, confirmed Toxicology data and Literals
Tabulate results for Level 4 in table shell provided
Obtain Multiple Cause Codes:1. Underlying Cause Codes2. Contributing Cause Codes
Use Multiple Cause Codes:X40-X44, X60-X64, X85, Y10-Y14, Y40-Y59, [F11-F16] (.0), F19.0,
T40.1,T40.2,T40.3,T40.4,T40.6,T43.6,T50.9
Level 4: Multistage Analysis
Part 1a
Part 1b
Part 1c Part 2
Underlying Code
Multiple/ Contributing Codes
How Injury Occurred Toxicology
Acute intoxication by the combined effects of Oxycodone, Morphine, Diazepam, and Cocaine
X42- T40.2 T50.9
Benzoylecgonine, Diazepam, Oxazepam, Oxycodone, Temazepam
Level 4 Summary
• Raises more questions than it answers?!
• Continue to refine this analysis
Acknowledgements
• CSTE Overdose sub-committee members• Safe States Members• CDC Staff• NYC DOHMH