The Overdose Crisis:View from Allegheny County

ACOPCSummer Conference

July 30, 2015

Karl E. Williams MD MPHChief Medical Examiner

Allegheny County

CDC - July 25, 2015http://www.cdc.gov/vitalsigns/heroin/

New News or Old?

Unintentional Drug Overdose Deaths in U.S. during 1999-2007

Opiate and HeroinOpiates and Opioids Heroin

WhyFlorida Experience

Number of prescriptions Heroin deaths

OD vs other CausesMore Old News

WhyHeroin Cost

Allegheny County

OD Death vs Rx

ODs by “Rural Status”

Ohio

Crude rates for drug overdose deaths and drug misuse-or abuse-related emergency department visit among women by select drug class

Snapshot - Europe

Heroin overdoses kill two in Pittsburgh area; others revived with Narcan

Wednesday, April 15, 2015Tribune Review

Two people are dead in the largest wave of heroin overdoses in the Pittsburgh area since a fentanyl-laced batch killed almost two dozen in 2014, officials said.

The Allegheny County Crime Lab is analyzing the stamp bags.

ACOME Drug Deaths as % of Morgue and Accidental Cases

2008 2009 2010 2011 2012 2013 20140.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

56.63% 57.77% 58.06%60.37%

64.51% 63.33%

67.64%

20.80%18.99% 19.62%

22.18%25.40%

23.58%21.30%

Drug Death as % Accidental Deaths Drug Death as % All Morgue Cases

ACOME Drug Deaths TotalSingle or Combined

Case Year

Total Drug Deaths

1 Drug 2 Drug 3 Drug 4 Drug 5 Drug 6 Drug 7 Drug

2012 288 111 78 59 27 11 1 1

2011 262 89 72 57 27 12 2 3

2010 227 61 69 52 28 9 1 7

2009 223 52 57 61 24 20 3 6

2008 235 81 56 58 22 13 2 3

ACOME Accidental Overdose Cases

Heroin; 138

Cocaine; 71Alcohol; 55

Fentanyl , 42

Alprazolam; 34

Morphine; 27

Oxycodone; 23

Methadone; 20

2014 Top 8 Drugs FoundSingle or Combined OD

HeroinCocaineAlcoholFentanylAlprazolamMorphineOxycodoneMethadone

Top Eight Drugs Found in Overdose Deaths

Heroin; 95

Cocaine; 83

Alcohol; 60

Oxycodone; 51

Alprazolam; 42

Methadone; 26

Diazepam; 25

Morphine; 24

2011 Top 8 Drugs FoundSingle or Combined OD

HeroinCocaineAlcoholOxycodoneAlprazolamMethadoneDiazepamMorphine

Heroin; 140

Alcohol; 73Cocaine; 68

Alprazolam; 36

Morphine; 31

Oxycodone; 31

Oxymor-phone; 26 Methadone; 22

2012 Top 8 Drugs FoundSingle or Combined OD

HeroinAlcoholCocaineAlprazolamMorphineOxycodoneOxymorphoneMethadone

Heroin; 146

Alcohol; 81Cocaine; 67

Alprazo-lam; 39

Oxy-codone; 35

Hy-drocodone;

26

Morphine; 20 Codeine; 18

2013 Top 8 Drugs FoundSingle or Combined OD

HeroinAlcoholCocaineAlprazolamOxycodoneHydrocodoneMorphineCodeine

Heroin; 138

Cocaine; 71Alcohol; 55

Fentanyl; 42

Alprazolam; 34

Morphine; 27

Oxycodone; 23

Methadone; 20

2014 Top 8 Drugs FoundSingle or Combined OD

HeroinCocaineAlcoholFentanylAlprazolamMorphineOxycodoneMethadone

Misclassification of Morphine Deaths

• Heroin undergoes rapid breakdown to 6MAM and then to morphine

• Heroin has a half-life of 9 minutes, and 6 MAM 39 minutes

• Morphine has a longer half-life (1.3-6.7 hours), and therefore depending on survival time might be the only drug detected

• In the absence of a drug history, stamp bags, or track marks, some heroin deaths may be classified as morphine deaths

• Fentanyl is an opioid analgesic.• First synthesized by Janssen Pharmaceuticals in the late 1950’s.• High potency with a short duration of action.• Fentanyl is 100x more potent than morphine.• Therapeutic Uses

– Utilized in surgical procedures as pre-anesthetic, primary anesthetic and for post surgical anesthesia

– Management of chronic pain• Transdermal patch (Duragesic)

– Breakthrough pain in cancer patients• Oral transmucosal fentanyl• Actiq (fentanyl lollipops), Fentora (Buccal tablets)

Fentanyl

• Transdermal patch• Fentanyl lipophilic, readily absorbed through

skin, releasing drug to blood stream for 72 hours.

• Allows for long lasting pain relief.

Duragesic Patch

Drug Reservoir

Release Membrane

ADHESIVEProtective Membrane

Backing

• Patches are abused by removing gel from package and injecting, smoking or ingesting contents.

• Patches may be frozen, cut into pieces and placed under tongue or in the cheek cavity for transmucosal absorption.

• Used patches abused due to the presence of a large percentage of fentanyl remaining in patches after 3 days of use.

Duragesic Patch:Illicit Uses

• 1979– Clandestine lab in California synthesized alpha-

methyl fentanyl

– Distributed it as a heroin substitute under the name “China White”

– Coined the term “Designer Drug”

Illicit Fentanyl Analogs/ Designer Drug

• Gary L. Henderson, professor at University of California School of Medicine, Dept. of Pharmacology

• Defined “Designer Drug” as:– Synthetic drug of abuse– Analog of the pharmaceutical fentanyl– Illicit laboratory producing an original drug– Not an illicit copy of the pharmaceutical– No clinical evaluations in humans– Not listed on DEA list of restricted drugs

“Designer Drug”

• 1979 – α-methylfentanyl

• 1984– α-methylacetylfentanyl

California Designer Drug Outbreak (1979-1984)

• 1984– 3-methylfentanyl

• Cis isomer: 6000x morphine• Trans isomer: 400x

morphine

• Overall identified 10 illicit analogs

• Extremely potent!!Fentanyl

• Emergency room at AGH and County Coroner (Dr. Perper) identified cases clinically consistent with overdose.– No detectable levels of common drugs of abuse.– Undercover narcotics agents purchased street drugs and submitted them to the lab.– Identified 3–methylfentanyl (TMF): 400x Morphine potency– Total number of deaths: 16 cases

• First instance of a designer drug outbreak outside of California– Calgon Chemist – Thomas Schaefers (47) responsible for the synthesis of 3-

methylfentanyl• Synthesis began in fall of 1987

– Distributor:• Cooperated with authorities• Received 11 years

– Schaefers:• Sentenced to 40 years

Fentanyl Outbreak 1: 1988

• Median Age: 36 (19-44)• Males (88%)• Most had prior history of drug abuse• Multiple drugs besides TMF were identified in

blood and tissues specimens (median 3 drugs)• 13 cases: cocaine or nonfentanyl opiates• 7 cases: morphine

Outbreak 1: 1988

• CDC/DEA surveillance system reported 1013 confirmed nonpharmaceutical fentanyl (NPF) deaths– Outbreaks of fentanyl overdoses and deaths in Delaware, Illinois, PA, NJ, Michigan and

Minnesota– In 2007 DEA listed N-phenethyl-4- piperidone (NPP), a precursor chemical used by

clandestine labs to illicitly manufacture fentanyl as a List 1 chemical– Distributor: New Jersey

• 27 Deaths in Allegheny County attributed to fentanyl alone or in combination with heroin.– Occurred from 4/23/06-7/24/06– Fentanyl was being packaged and sold on street in same manner as

heroin.

Outbreak 2: 2006

• CDC/DEA surveillance system reported 1013 confirmed nonpharmaceutical fentanyl (NPF) deaths

• In 2007 DEA listed N-phenethyl-4- piperidone (NPP), a precursor chemical used by clandestine labs to illicitly manufacture fentanyl as a List 1 chemical

Clandestine Manufacture: April 2005-March 2007

• Drug Stamp Bags submitted to lab:– ≈100 Stamp Bags

• 50% contained fentanyl only• 50% contained fentanyl combined with heroin

– Bags identified with Stamps:• “Get High or Die Trying”• “Burn Out”• “Way to go/Don diva”• “Tiffany”• “Fendi”• “Truth”

Outbreak 2: 2006 (cont.)

• Short Duration – 2 weeks

• Pittsburgh Post Gazette: February 1, 2014– “Tests confirm fentanyl-

laced heroin led to 14 overdose deaths in Allegheny County.”

Outbreak 3: 2014

• Law Enforcement:– Local – Pittsburgh Narcotics– State – Attorney Generals Office– Federal – US Drug Enforcement Agency

• All worked overtime and set up tip-lines in an effort to get the potent heroin off the streets.

• Efforts worked: Only 1 cases involving fentanyl since January 31, 2014

Outbreak 3: 2014 (cont.)

• ACOME: Rash of overdose deaths in two week period (1/16-1/29).

• Stamp bags submitted in Death Investigation marked “Theraflu” and “Bud Ice.”

• Expedited testing of stamp bags revealed presence of heroin and fentanyl.

• Expedited ELISA screening of blood revealed presumptive positive results for opiates and fentanyl.

Outbreak 3: 2014

• Friday – January 24– Three “Probable” ODs in autopsy room– Outlier for ODs– Fentanyl ordered from Drug Chemistry was positive

• Saturday – January 25– All four cases obvious drug overdoses

• Sunday – January 26 – Three of five cases obvious drug overdoses

• Tuesday/Wednesday– Pure white powder composed of 50/50 Heroin and fentanyl found in

both evidence from death scenes and in seized material from drug busts

– Powder identified in only two the multitude of stampbags– Prominent peaks of heroin and fentanyl identified in the blood of

overdose victims.

Overdose crisis in Southwest PA

January 2014Before and after Jan 16

COR # LAB # Age Gender Race Preliminary TOX Results

14-0073 1/4/14 14-00120 29 FEMALE WHITE CARRICKOpiate pos CPR,BUTLER

14-0128 1/6/14 14-00217 24 MALE WHITE JEFF.HILLS UNKNOWN Opiate pos

14-0282 1/11/14 14-00347 26 MALE WHITE HARRISON TWPOpiate pos PASSION

14-0296 1/12/14 14-0430 29 FEMALE WHITE MT. WASHINGTON

Opiate pos TUNAFISH

14-0296 1/12/14 14-00431 43 MALE WHITE GLASSPORTOpiate pos UNKNOWN

14-0340 1/13/14 14LAB00465 70 MALE BLACK E. PITTSBURGH

Opiate pos POKER

14-0412 1/16/14 14LAB00568 29 MALE WHITE E. LIBERTY

Opiate posFentanyl pos

MULTIPLE – BUD ICE, PASSION, INCOME TAX, GORILLA, see story for more

14-0414 1/17-14 14LAB00570 26 MALE WHITE WEST ENDOpiate pos

Fentanyl pos UNKNOWN14-0478 1/18/14 14LAB00591 48 FEMALE BLACK DOWNTOWN

Opiate posFentanyl pos

GUCCI, DIESEL, LSI

14-0493 1/19/14 14LAB00589 25 FEMALE WHITE WEST END Opiate posFentanyl pos LUCKY CHARMS

January 19-2514-0493 1/19/14 14LAB00589 25 FEMALE WHITE WEST END

Opiate posFentanyl pos LUCKY CHARMS

14-0519 1/20/14 14LAB00686 51 MALE WHITE PENN HILLSOpiate pos GREEN LIGHT

14-0537 1/21/14 14LAB00716 48 MALE WHITE ASPINWALL Opiate posFentanyl pos BUD ICE

14-0565 1/22/14 14LAB00761 31 MALE WHITE THERAFLU Opiate pos Fentanyl pos

14-0582 1/23/14 14LAB00764 50 MALE WHITE SQUIRRELL HILLOpiate pos

Fentanyl pos THERAFLU

14-0583 1/23/14 14LAB00765 26 MALE WHITE BELTZHOOVEROpiate posFentayl pos NO STAMP

14-0620 1/24/14 14LAB00801 46 MALE WHITE E. LIBERTYOpiate posFentayl pos

UNKNOWN STAMP

14-0600 1/23/14 14LAB00798 45 MALE WHITE TARENTUM

Opiate posFentayl pos

THERAFLU, LIFE SUPPORT, DIESEL, BUD ICE, CHECK MATE, TOM FORD

14-0592 1/23/14 14LAB00797 46 FEMALE WHITE PENN HILLSOpiate posFentayl pos

MAGIC CITY

14-0632 1/25/14 14LAB00802 30 FEMALE WHITE BUD ICE,

Opiate posFentayl pos

TROY HILL INCOME TAX, DR. PEPPER, BEST

BUY

14-0655 1/25/14 14LAB00820 36 MALE WHITE BLOOMFIELDOpiate pos

Fentanyl pos THERAFLU

Before and after January 2514-0655 1/25/14 14LAB00820 36 MALE WHITE BLOOMFIELD

Opiate posFentanyl pos

THERAFLU

14-0658 1/25/14 14LAB00819 29 MALE WHITE CASTLE SHANNONOpiate pos

Fentanyl pos BUD ICE

14-0704 1/27/14 14LAB00905 46 FEMALE WHITE KNOXVILLE Opiate posFentanyl ND MAGIC CITY

14-0753 1/29/14 14LAB01001 40 MALE WHITE GREENTREE CITYOPIATE POS

FENTANYL ND CVS

14-0802 1/31/14 14LAB01037 30 MALE WHITE BLOOMFIELD SCORPION OPIATE POSFENTANYL ND

14-0943 2/6/14 14LAB01248 51 FEMALE WHITE OAKMONT THERAFLU Fentanyl NDOpiate ND

14-1018 2/9/14 14LAB01324 54 MALE WHITE NORTH SIDE TOTAL CONTROL

Fentanyl NDOpiate pos

14-1043 2/10/14 14LAB01422 23 MALE WHITE MONROEVILLE Fentanyl ND Opiate pos

14-1138 2/13/14 14LAB01452 42 MALE WHITE BELTZHOOVER UNMARKED

Pending14-1232 2/16/14 14LAB01490 24 MALE WHITE NORTHSIDE SPARTICUS PENDING

14-9382/6/2014

14LAB01247 43 MALE BLACK Fentanyl NDOpiate pos

Stamp bags – seized and from death scenes

Bud Ice Theraflu

Some final thoughts - 1

• What is Old is only historical interest. It can provide lessons, but cannot dictate public policy for a situation that is rapidly changing and inevitably has a unique quality at the local level.– Hence the importance of the availability of those

dealing with the problem to apply LOCAL knowledge of the drugs in one particular area

Some final thoughts - 2• Incredible complexity of Forensic Toxicology and the Tox report

– OMEAC has a full-time Forensic Toxicologist to help with the almost 300 cases a year – and only one report format to deal with!• Sampling of 4+ sites• Post-mortem redistribution• Ante and post mortem redistribution• Issue of POST-MORTEM drug levels versus levels in the living!!!

• Coroners and Medical Examiners System – PA– Available resources – limited

• Westmoreland vs. Clarion– No standardization of the Death Certificate

• List of drugs vs. “Combined Drug Toxicity

The Future

• Expand participating counties– Begin to develop a picture of SW Pennsylvania –

PEMA Region 13– Provide support to local communities through

identification of resources and specifics of local OD problem

• A drug overdose dataset the includes LEVELS or drugs and metabolites

• Provide Forensic Toxicology support for efforts

Thank You

?• Acknowledgments– Jennifer Jansen and the Toxicology Division– Joshua Yohanna and the Drug Chemistry Division– Patria Reikel– Department of Computer Services

• Allegheny County Overdose Prevention Coalition– http://www.overdosefreepa.pitt.edu/