nc dhhs injury and violence prevention branch, 10/27/2005 1 a public health response to an epidemic...

NC DHHS Injury and Violence Prevention Branch, 10/27/2005 1

A Public Health Response to an Epidemic of Fatal Drug Overdoses

in North Carolina

Catherine (Kay) Sanford, MSPH

Injury and Violence Prevention BranchDivision of Public Health, NC-DHHS

[email protected]


NC’s Public Health Steps

1. CDC-NCIPC Injury Indicator Report2. EIS Investigation – Fatal Poisonings in NC3. Task Force on Unintentional Drug Overdoses4. MMWR on Unintentional Drug Overdoses in

11 states5. Task Force Recommendations6. NC-DOJ/DHHS Leadership Committee on

Drug Overdoses7. Year 1: Surveillance and PMP Legislation


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.


Age-Adjusted Mortality Rates of Selected Injuries, United States: 1991-2000

02468

1012141618

Mor

talit

y R

ates

/100

,000

Falls

Fire/Burns

Firearms

MVC

Poisons


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)


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


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.


Comparing NC injury trends to that of the nation.

Intentional and Unintentional Poisoning Crude Death Rates in the US and NC: 1997-2001

6.817.24 7.35

7.8

5.51

6.96

7.73

6.61

5.444.77

0123456789

1997 1998 1999 2000 2001

Cru

de

Rat

es /

100,

000

USNC

WISQARS:www.cdc.gov/ncipc/ 1-2004


NC Resident Deaths Due to Poisoning by Manner/Intent: 1997 – 2001

228 230

279

367

437

126149 141

169 186

1 3 2 3 419 24 19 22 11

380406

440

560

638

0

100

200

300

400

500

600

700

1997 1998 1999 2000 2001

Num

ber

of D

eath

s

UnintentionalSuicideHomicideUndeterminedTotal


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


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


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 (E850-E858; X40-X44) with a death certificate on file at the NC State Center for Health Statistics.


ME Chart Abstraction

1096316278190155157ME Abstraction

83.081.087.481.281.284.0% of VS

1320390318234191187Vital Stats

97-0120012000199919981997


Deaths from Unintentional Drug Overdoses from NC ME Data (n=1,096) by Age and Sex : 1997-2001

1 721 23

3869 73

5332

10 202

17

5576

103

154 156

111

40

1916

0

50

100

150

200

250

0-14 15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60+

Num

ber

Die

d

MalesFemales


Unintentional Drug Deaths by Race from Abstracted ME Records (N=1096) in NC: 1997-2001

41 28 42 53 53

116 127148

225263

0

50

100

150

200

250

300

350

1997 1998 1999 2000 2001

Num

ber

Die

d

Not White White


Unintentional Drug Deaths by Sex from Abstracted ME Records (N=1096) in NC: 1997-2001

Males:

N=749

68.3%

Females:

N=347

31.7%


Unintentional Drug Deaths by Sex and Year from Abstracted ME Records (N=1096) in NC: 1997-2001

119111

128

193 198

38 44

62

85

118

0

50

100

150

200

250

1997 1998 1999 2000 2001

Num

ber

Die

d

Males: 66% increaseMales: 66% increase Females: 210% increaseFemales: 210% increase


Scene/dead59%

Rx @ Scene/died

8%

Rx @ ED/died17%

Transported/ DOA9%

Hospital/died7%

Treatment Provided Prior to Deaths from Unintentional Drug Overdoses from Medical Examiner Data in North

Carolina: 1997-2001

DOA = dead on arrivalED = emergency departmentRx = treatment

(1,096 ME cases)


Unintentional Drug Deaths by Past Medical History from Abstracted ME Records (N=1096)

in NC: 1997-2001

20.4%Mental Health

20.1%Chronic Pain

23.8%Alcohol Abuse/Alcoholism

53.8%Drug Abuse


Decedents’ Source of Drugs from NC Medical Examiner Records by Sex : 1997-2001

48

22

2 1

3328

33

2 2

34

0

10

20

30

40

50

60

Street

Dru

gs

Presc

riptio

ns D

eced

ent

Presc

riptio

ns O

ther

Illeg

al a

nd P

resc

riptio

n

Sourc

e Unkn

own

Pe

rce

nt

of

De

ath

s

MaleFemale


Deaths Resulting From a Single Drug by Type and Sex, NC Medical Examiner

Records: 1997-2001

2724

19

75 5

26

8

22

74

7

0

5

10

15

20

25

30

Cocaine

Heroin

Methadone

Morphin

e

Oxyco

done

Fenta

nyl

Per

cent

of

Dea

ths

MaleFemale


1997n=117

1998n=109

1999n=131

2000n=197

2001n=226

‘97-’01n=780

Cocaine52 (44%)

Heroin32 (29%)

Cocaine44 (34%)

Methadone56 (28%)

Methadone58 (26%)

Cocaine221 (28%)

Heroin23 (20%)

Cocaine31 (28%)

Heroin30 (23%)

Cocaine48 (24%)

Cocaine46 (20%)

Heroin147 (19%)

Morphine 9 (8%)

Fentanyl 7 (6%)

Methadone19 (15%)

Heroin31 (16%)

Heroin31 (14%)

Methadone147 (19%)

Methadone 7 (6%)

Methadone 7 (6%)

Morphine 5 (4%)

Morphine15 (8%)

Oxycodone19 (8%)

Morphine53 ( 7%)

Fentanyl 6 (5%)

Morphine 7 (6%)

Fentanyl 4 (3%)

Oxycodone14 (7%)

Morphine17 (8%)

Fentanyl42 (5%)

Propoxyphene

5 (4%)Propoxyphene

2 (2%)Hydrocodone

4 (3%)Fentanyl11 (6%)

Fentanyl14 (6%)

Oxycodone38 (5%)

Unintentional Deaths from a Single Drug:

Illicit Drugs, North Carolina, 1997-2001


1997 n=117

1998 n=109

1999 n=131

2000 n=197

2001 n=226

‘97-’01 n=780

Cocaine 52 (44%)

Heroin 32 (29%)

Cocaine 44 (34%)

Methadone 56 (28%)

Methadone 58 (26%)

Cocaine 221 (28%)

Heroin 23 (20%)

Cocaine 31 (28%)

Heroin 30 (23%)

Cocaine 48 (24%)

Cocaine 46 (20%)

Heroin 147 (19%)

Morphine 9 (8%)

Fentanyl 7 (6%)

Methadone 19 (15%)

Heroin 31 (16%)

Heroin 31 (14%)

Methadone 147 (19%)

Methadone 7 (6%)

Methadone 7 (6%)

Morphine 5 (4%)

Morphine 15 (8%)

Oxycodone 19 (8%)

Morphine 53 ( 7%)

Fentanyl 6 (5%)

Morphine 7 (6%)

Fentanyl 4 (3%)

Oxycodone 14 (7%)

Morphine 17 (8%)

Fentanyl 42 (5%)

Propoxyphene

5 (4%) Propoxyphene

2 (2%) Hydrocodone

4 (3%) Fentanyl 11 (6%)

Fentanyl 14 (6%)

Oxycodone 38 (5%)

Unintentional Deaths from a Single Drug:

Licit Drugs North Carolina, 1997-2001


Unintentional Deaths from Multiple Drugs:North Carolina, 1997-2001

1997 1998 1999 2000 2001 97-01Alcohol17 (43%)

Cocaine18 (39%)

Alcohol21 (36%)

Alcohol26 (32%)

Cocaine25 (28%)

Alcohol99 (31%)

Cocaine14 (35%)

Heroin18 (39%)

Cocaine14 (24%)

Oxycodone21 (26%)

Oxycodone22 (24%)

Cocaine90 (28%)

Heroin10 (25%)

Alcohol14 (30%)

Methadone10 (17%)

Cocaine19 (23%)

Methadone22 (24%)

Heroin58 (18%)

Hydrocodone8 (20%)

Morphine8 (17%)

Oxycodone6 (10%)

Hydrocodone12 (15%)

Alcohol21 (23%)

Oxycodone52 (16%)

Morphine3 (8%)

Hydrocodone5 (11%)

Hydrocodone6 (10%)

Methadone11 (14%)

Hydrocodone19 (21%)

Methadone51 (16%)

Alprazolam3 (8%)

Alprazolam5 (11%)

Alprazolam6 (10%)

Alprazolam11 (14%)

Heroin13 (14%)

Hydrocodone50 (16%)

No. deaths = 316


300%

729%

93%

% change from

97 to 01

96

51

109

Number

Change

88.1%12832All Rx Narcotics

46.7%587Methadone

----- 226117All Poisoning deaths

% of overall

increase

20011997

Deaths Resulting From a Single Drug (n=780):

Change from 1997 to 2001


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.


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.


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.


Medical Practice

PharmacyCo-chaired by

State Epidemiologist and Ass’t Director SBI

Substance Abuse Services

Medical Examiners

ToxicologyState and Federal Law Enforcement

Epidemiologic Surveillance

Public Health

Injury Prevention Specialists

Law and Criminal Justice

North Carolina Task Force to Prevent Deaths

from Unintentional Drug Overdoses

Mental Health


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.


Pre-event

Event

Post-event

Host Agent/ vehicle

Physical environment Social

environment

Effectiveness

Cost

Freedom

Equity

Stigmatization

Other identified criteria

Feasibility

Preferences

Factors

Decision Criteria

Phases

Three Dimensional Haddon Matrix

Adapted from Runyan, CW. Injury Prevention, 1998(4), 302-307


4. MMWR on Unintentional Drug Overdoses in 11 states

1. Concomitant research within the state and with other states on increases in unintentional drug-related deaths.

2. Findings continued to support increasing deaths.

3. Published MMWR: March 26, 2004 (vol.53#11).


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 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.



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.



3. LAW ENFORCEMENT recommendations

provide infrastructure to prevent illegal

distribution and use of controlled medications.



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.



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.



6. EDUCATIONAL INTERVENTIONS – PROFESSIONALS recommendations to raise professional awareness about themagnitude, risks and signs of unintentionaloverdose and create practice guidelines andeducational and credentialling requirementsfor prevention, treatment and enforcementactivities.



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.


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


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 Resident Deaths Due to Poisoning by Manner/Intent: 1997 – 2004

228 230279

367437

547

690729

126 149 141 169 186155 151

184

1 3 2 3 4 0 219 24 19 22 11 20 25

380 406440

560638

722

868

0

100200

300

400500

600

700

800900

1000

1997 1998 1999 2000 2001 2002 2003 2004

Num

ber

of D

eath

s

UnintentionalSuicideHomicideUndeterminedTotal

SURVEILLANCE


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.

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.

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.

LEGISLATION


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 1 a public health response to an epidemic...

Documents

nc dhhs injury

nc injury program

nc injury trends

msph injury

nc resident deaths

drugsubstance slide

nc state health director

unintentional drug overdoses