scholarly journals Improving risk factor identification for opioid overdose deaths in Tennessee

2019 ◽  
Vol 11 (1) ◽  
Author(s):  
Sarah J. Nechuta ◽  
Jenna Moses ◽  
Molly Golladay ◽  
Adele Lewis ◽  
Julia Goodin ◽  
...  
Keyword(s):  
Risk Factor ◽  
Drug Overdose ◽  
Medical Examiner ◽  
Prescription Opioid ◽  
Opioid Overdose ◽  
Prescription Opioids ◽  
Death Certificates ◽  
Postmortem Toxicology ◽  
Icd 10 ◽  
Overdose Deaths

ObjectiveTo examine specific drugs present based on postmortem toxicology for prescription opioid, heroin, and fentanyl overdoses classified based on ICD-10 coding. To compare drugs identified from postmortem toxicology with those listed on the death certificate for opioid overdoses.IntroductionUsing death certificates alone to identify contributing substances in drug overdose deaths may result in misclassification and underestimation of the burden of illicit and prescription opioids and other drugs in drug-related deaths. To enable timely and targeted prevention in Tennessee (TN), the identification and monitoring of new drugs and trends in use should utilize toxicology and medicolegal death investigation data directly, as recommended by others 1-3. These data can inform mortality outcome definitions for improved surveillance and risk factor identification 4-7. To our knowledge, this is the first analysis to use statewide linked toxicology and death certificate data in TN.MethodsWe identified 615 opioid involved overdose deaths in TN of unintentional (underlying ICD-10 codes: X40-X44) or undetermined (underlying ICD-10 codes: Y10-Y14) intent during June 1st to December 31st 2017. Utilizing the Interim Medical Examiner Database (I-MED), we identified postmortem toxicology reports for 454 cases, which were from one of three national laboratories used by a state Regional Forensic Center. Toxicology data were abstracted and independently verified by two co-authors and linked to the TN death statistical file that included cause of death information (literal text and ICD-10 codes) and demographics. The analysis focuses on cases with an available toxicology report.ResultsWe identified 171 prescription opioid overdoses, 221 fentanyl overdoses, and 113 heroin overdoses. Table 1 displays postmortem toxicology profiles for major drugs/classes. For prescription opioid deaths (excluding fentanyl and heroin), positive toxicology results for prescription opioids were as follows: methadone (11%), buprenorphine (14%), hydrocodone (14%), oxycodone (36%) and oxymorphone (also a metabolite, 47%). Benzodiazepines were present in close to 58% of prescription opioid overdoses; stimulants (cocaine, amphetamines, methamphetamines) in about 25%. For fentanyl and heroin deaths, prescription opioids were detected in about 26% and 34%, respectively; stimulants in about 57.9% and 52.2%, respectively, and benzodiazepines 36-37%. Fentanyl was present on toxicology in about half of heroin overdoses, and 6–monoacetylmorphine in 72.6%.ConclusionsUsing medical examiners’ data, including toxicology data, improves estimation of contributing drugs involved in opioid deaths. This analysis provides jurisdiction-specific data on drugs that can help with monitoring trends and informs risk factor identification. Future work includes adding information on prescribed opioid and benzodiazepines using TN’s Prescription Drug Monitoring Database and evaluating demographic variation in contributing drugs between toxicology and DC data to identify susceptible populations.References1. Slavova S, O'Brien DB, Creppage K, Dao D, Fondario A, Haile E, Hume B, Largo TW, Nguyen C, Sabel JC, Wright D, Council of S, Territorial Epidemiologists Overdose S. Drug Overdose Deaths: Let's Get Specific. Public Health Rep.2. Horon IL, Singal P, Fowler DR, Sharfstein JM. Standard Death Certificates Versus Enhanced Surveillance to Identify Heroin Overdose-Related Deaths. Am J Public Health. 2018;108(6):777-81.3. Mertz KJ, Janssen JK, Williams KE. Underrepresentation of heroin involvement in unintentional drug overdose deaths in Allegheny County, PA. J Forensic Sci. 2014;59(6):1583-5.4. Landen MG, Castle S, Nolte KB, Gonzales M, Escobedo LG, Chatterjee BF, Johnson K, Sewell CM. Methodological issues in the surveillance of poisoning, illicit drug overdose, and heroin overdose deaths in new Mexico. Am J Epidemiol. 2003;157(3):273-8.5. Davis GG, National Association of Medical E, American College of Medical Toxicology Expert Panel on E, Reporting Opioid D. Complete republication: National Association of Medical Examiners position paper: Recommendations for the investigation, diagnosis, and certification of deaths related to opioid drugs. J Med Toxicol. 2014;10(1):100-6.6. Slavova S, Bunn TL, Hargrove SL, Corey T. Linking Death Certificates, Postmortem Toxicology, and Prescription History Data for Better Identification of Populations at Increased Risk for Drug Intoxication Deaths. Pharmaceutical Medicine. 2017;31(3):155-65.7. Hurstak E, Rowe C, Turner C, Behar E, Cabugao R, Lemos NP, Burke C, Coffin P. Using medical examiner case narratives to improve opioid overdose surveillance. Int J Drug Policy. 2018;54:35-42. 

scholarly journals Impact of a Drug Overdose Decedent Toxicology Testing Legislative Mandate on Informing Coroner Death Investigation and Certification Practices

2019 ◽  
Vol 9 (1-2) ◽  
pp. 66-80
Author(s):  
Dana Quesinberry ◽  
Terry L. Bunn ◽  
Sarah Hargrove ◽  
Svetla Slavova
Keyword(s):  
Drug Overdose ◽  
Policy Implication ◽  
Influence Factors ◽  
Death Certificates ◽  
Postmortem Toxicology ◽  
Poisoning Deaths ◽  
Death Investigation ◽  
The Impact ◽  
Overdose Deaths ◽  
And Training

Objective: To (a) determine the impact of Kentucky’s (KY’s) mandate requiring postmortem toxicology testing of coroner cases; (b) identify the influence of coroner experience and training, jurisdiction size, budget, and location on postmortem testing requests; (c) identify facilitators/barriers for postmortem toxicology testing requests and listing the specific drugs involved in drug-poisoning deaths on death certificates. Methods: A modified Dillman approach was used to deliver the survey to KY’s elected coroners between April and May 2016. Responses stratified by identified influence factors were compared using χ2 tests and Fisher exact tests. Results: Fifty-eight percent of coroners reported that drug overdose investigations had changed since the mandate was enacted. Statistically significant differences in responses were found when stratified. Sixty-three percent of coroners reported always using testing results to complete death certificates. Conclusions: Uptake of the mandate for postmortem toxicology testing of all decedents is not yet complete. Policy Implication: Without uptake of the mandate, surveillance efforts may result in undercounting of drug overdose deaths and the involvement of specific drugs. Mandates for enhanced training and modification of funding structure for medico-legal death investigations could facilitate uptake.

Improvements in Toxicology Testing to Identify Fentanyl Analogs and Other Novel Synthetic Opioids in Fatal Drug Overdoses, Connecticut, January 2016–June 2019

2021 ◽  
Vol 136 (1_suppl) ◽  
pp. 80S-86S
Author(s):  
Heather A. Clinton ◽  
Shobha Thangada ◽  
James R. Gill ◽  
Amy Mirizzi ◽  
Susan B. Logan
Keyword(s):  
Drug Overdose ◽  
Drug Market ◽  
Medical Examiner ◽  
Testing Methods ◽  
Synthetic Opioids ◽  
Postmortem Toxicology ◽  
Drug Overdoses ◽  
Fentanyl Analogs ◽  
Novel Synthetic Opioids ◽  
Overdose Deaths

Objectives Drug overdose deaths in Connecticut increasingly involve a growing number of fentanyl analogs and other novel nonfentanyl synthetic opioids (ie, novel synthetics). Current postmortem toxicology testing methods often lack the sophistication needed to detect these compounds. We examined how improved toxicology testing of fatal drug overdoses can determine the prevalence and rapidly evolving trends of novel synthetics. Methods From 2016 to June 2019, the Connecticut Office of the Chief Medical Examiner increased its scope of toxicology testing of suspected drug overdose deaths in Connecticut from basic to enhanced toxicology testing to detect novel synthetics. The toxicology laboratory also expanded its testing panels during this time. We analyzed toxicology results to identify and quantify the involvement of novel synthetics over time. Results From 2016 to June 2019, 3204 drug overdose deaths received enhanced toxicology testing; novel synthetics were detected in 174 (5.4%) instances. Ten different novel synthetics were detected with 205 total occurrences. Of 174 overdose deaths with a novel synthetic detected, most had 1 (n = 146, 83.9%) or 2 (n = 26, 14.9%) novel synthetics detected, with a maximum of 4 novel synthetics detected. Para-fluorobutyrylfentanyl/FIBF, furanylfentanyl, and U-47700 were most identified overall, but specific novel synthetics came in and out of prominence during the study period, and the variety of novel synthetics detected changed from year to year. Conclusions Enhanced toxicology testing for drug overdose deaths is effective in detecting novel synthetics that are not identified through basic toxicology testing. Identifying emerging novel synthetics allows for a timely and focused response to potential drug outbreaks and illustrates the changing drug market.

Economic Conditions and Drug and Opioid Overdose Deaths

2017 ◽  
Vol 76 (4) ◽  
pp. 462-477 ◽  
Author(s):  
Ezequiel Brown ◽  
George L. Wehby
Keyword(s):  
Drug Overdose ◽  
Fixed Effects ◽  
House Prices ◽  
Insurance Coverage ◽  
House Price ◽  
State Level ◽  
Economic Conditions ◽  
Prescription Opioid ◽  
Opioid Overdose ◽  
Overdose Deaths

We examine the effects of state-level economic conditions including unemployment rates, median house price, median household income, insurance coverage, and annual and weekly work time on deaths on drug overdose deaths including from opioids and prescription opioids between 1999 and 2014. We employ difference-in-differences estimation controlling for state and year fixed effects, state-specific time trends, and demographic characteristics. Drug overdose deaths significantly declined with higher house prices, an effect driven by reduction in prescription-opioid mortality, by nearly 0.17 deaths per 100,000 (~4%) with a $10,000 increase in median house price. House price effects were more pronounced and only significant among males, non-Hispanic Whites, and individuals younger 45 years. Other economic indicators had insignificant effects. Our findings suggest that economic downturns that substantially reduce house prices such as the Great Recession can increase opioid-related deaths, suggesting that efforts to control access to such drugs should especially intensify during these periods.

scholarly journals The Economic Underpinnings of the Drug Epidemic

2019 ◽  
Author(s):  
Nathan Seltzer
Keyword(s):  
Labor Market ◽  
Labor Markets ◽  
Drug Overdose ◽  
Manufacturing Sector ◽  
State Level ◽  
Opioid Overdose ◽  
Transformative Change ◽  
Drug Deaths ◽  
Overdose Deaths ◽  
The U.S

U.S. labor markets have experienced transformative change over the past half century. Spurred on by global economic change, robotization, and the decline of labor unions, state labor markets have shifted away from an occupational regime dominated by the production of goods to one characterized by the provision of services. Prior studies have proposed that deterioration of employment opportunities may be associated with the rise of substance use disorders and drug overdose deaths, yet no clear link between changes in labor market dynamics in the U.S. manufacturing sector and drug overdose deaths has been established. Using restricted-use vital registration records between 1999-2017 that comprise over 700,000 drug deaths, I test two questions. First, what is the association between manufacturing decline and drug and opioid overdose mortality rates? Second, how much of the increase in these drug-related outcomes can be accounted for by manufacturing decline? The findings provide strong evidence that restructuring of the U.S. labor market has played an important upstream role in the current drug crisis. Up to 77,000 overdose deaths for men and up to 40,000 overdose deaths for women are attributable to the decline of state-level manufacturing over this nearly two-decade period. These results persist in models that adjust for other social, economic, and policy trends changing at the same time, including the supply of prescription opioids. Critically, the findings signal the value of policy interventions that aim to reduce persistent economic precarity experienced by individuals and communities, especially the economic strain placed upon the middle class.

Drug overdose deaths at work, 2011–2016

2019 ◽  
Vol 25 (6) ◽  
pp. 577-580 ◽  
Author(s):  
Hope M Tiesman ◽  
Srinivas Konda ◽  
Lauren Cimineri ◽  
Dawn N Castillo
Keyword(s):  
Drug Overdose ◽  
Negative Binomial ◽  
Occupational Injuries ◽  
Negative Binomial Regression ◽  
Opioid Overdose ◽  
Full Time ◽  
Demographic Groups ◽  
Drug Overdoses ◽  
The Impact ◽  
Overdose Deaths

Drug overdose fatalities have risen sharply and the impact on US workplaces has not been described. This paper describes US workplace overdose deaths between 2011 and 2016. Drug overdose deaths were identified from the Census of Fatal Occupational Injuries and fatality rates calculated using denominators from the Current Population Survey. Fatality rates were compared among demographic groups and industries. Negative binomial regression was used to analyse trends. Between 2011 and 2016, 760 workplace drug overdoses occurred for a fatality rate of 0.9 per 1 000 000 full-time equivalents (FTEs). Workplace overdose fatality rates significantly increased 24% annually. Workplace overdose fatality rates were highest in transportation and mining industries (3.0 and 2.6 per 1 000 000 FTEs, respectively). One-third of workplace overdose fatalities occurred in workplaces with fewer than 10 employees. Heroin was the single most frequent drug documented in workplace overdose deaths (17%). Workplace overdose deaths were low, but increased considerably over the six-year period. Workplaces are impacted by the national opioid overdose epidemic.

Accidental Overdose Deaths in Oklahoma, 2002–2017: Opioid and Methamphetamine Trends

2020 ◽  
Vol 44 (7) ◽  
pp. 672-678
Author(s):  
Rachel Bonk ◽  
Ross J Miller ◽  
Joshua Lanter ◽  
Cheryl Niblo ◽  
Jesse Kemp ◽  
...  
Keyword(s):  
Drug Overdose ◽  
Sharp Increase ◽  
The State ◽  
Prescription Opioids ◽  
Opioid Epidemic ◽  
Death Rates ◽  
Synthetic Opioids ◽  
Accidental Overdose ◽  
Overdose Deaths

Abstract To evaluate trends related to accidental overdose deaths in Oklahoma, with a focus on opioids and methamphetamine. All accidental drug overdose deaths in the state of Oklahoma from 2002 to 2017 were reviewed. Opioids were grouped into the following categories: all opioids, prescription opioids, synthetic opioids and heroin. Age-adjusted death rates for methamphetamine and each opioid category were calculated and analyzed. Accidental overdoses accounted for 9,936 deaths during the study period. Of these, opioids were seen in 62.9%, with prescription opioids comprising 53.8%, synthetic opioids 10.3% and heroin 2.8%. Synthetic opioids, despite a recent upward nationwide trend, showed a slight overall decrease (−6.8%) from 2009 to 2017. In contrast, methamphetamine showed a 402.2% increase from 2009 to 2017 and an overall increase of 1,526.7%. Methamphetamine was involved in the most overdoses (1,963), followed by oxycodone (1,724). Opioid-related deaths were most common among white individuals (90.3%) and showed a slight male predilection (56.9%). With the intent of assessing the opioid epidemic as it relates to accidental overdoses in Oklahoma, this study suggests that opioid-related overdoses have slowed in recent years amidst a sharp increase in methamphetamine deaths.

Fentanyl analogue overdose: Key lessons in management in the synthetic opioid age

2019 ◽  
Vol 15 (5) ◽  
pp. 428-432
Author(s):  
Amer Raheemullah, MD ◽  
Neal Andruska, MD, PhD
Keyword(s):  
Addiction Treatment ◽  
Opioid Use Disorder ◽  
Prescription Opioid ◽  
Opioid Overdose ◽  
Health Departments ◽  
Opioid Use ◽  
Public Health Departments ◽  
Disorder Treatment ◽  
Fentanyl Analogues ◽  
Overdose Deaths

Fentanyl overdoses are growing at an alarming rate. Fentanyl is often mixed into heroin and counterfeit prescription opioid pills without the customer’s knowledge and only detected upon laboratory analysis. This is problematic because fentanyl analogues like carfentanil are 10,000 times more potent than morphine and pose new challenges to opioid overdose management. A 62-year-old male with an overdose from a rare fentanyl analogue, acrylfentanyl, was given two doses of intranasal 2 mg naloxone with improvements in respiratory rate. In lieu of more naloxone, his trachea was intubated and he was admitted to the intensive care unit. He subsequently developed ventilator-associated pneumonia and then a pulmonary embolism. He did not receive any opioid use disorder treatment and returned back to the emergency department with an opioid overdose 21 days after discharge.We are encountering an unprecedented rise in synthetic opioid overdose deaths as we enter the third decade of the opioid epidemic. Thus, it is imperative to be aware of the features and management of overdoses from fentanyl and its analogues. This includes protecting against occupational exposure, administering adequate doses of naloxone, and working with public health departments to respond to fentanyl outbreaks. Additionally, fentanyl overdoses represent a critical opportunity to move beyond acute stabilization, start buprenorphine or methadone for opioid use disorder during hospitalization, link patients to ongoing addiction treatment, and distribute naloxone into the community to help curb the overdose epidemic.

scholarly journals Linking Emergency Medical Service Data to Death Records for Opioid Mortality Surveillance

2019 ◽  
Vol 11 (1) ◽  
Author(s):  
Joseph R. Tatar ◽  
Jennifer Broad
Keyword(s):  
Public Health ◽  
Emergency Medical Service ◽  
Cause Of Death ◽  
Emergency Response ◽  
Drug Overdose ◽  
Medical Service ◽  
Medical Examiner ◽  
Opioid Overdose ◽  
Naloxone Administration ◽  
Underlying Cause Of Death

ObjectiveTo identify the correlates of opioids as an underlying cause of death by linking coroner/medical examiner vital death records with emergency medical service (EMS) ambulance run data. By combining death data to EMS ambulance runs, the goal was to determine characteristics of the emergency response—particularly for opioid overdose events—that may connect to increased mortality.IntroductionOpioid abuse has increased exponentially in recent years throughout the United States, leading to an increase in the incidence of emergency response activities, hospitalization, and mortality related to opioid overdose. As a result, states that have been hit particularly hard during this period—such as Wisconsin—have allocated considerable resources to addressing this crisis via enhanced public health surveillance and outreach, procurement and administration of medical countermeasures, prescription drug monitoring programs, targeted preventive and acute treatment, first responder and hospital staff training, cross-agency collaboration, and Incident Management System activities. Central to these efforts is the identification of the primary drivers of opioid overdose and death to improve the precision and efficacy of targeted public health interventions to address the opioid crisis. The present study sought to accomplish this end by syncing rich data sources at the point of emergency response (EMS ambulance runs) to ultimate mortality outcomes (vital death records).MethodsIn the State of Wisconsin, data systems supporting the surveillance of EMS ambulance runs and coroner/medical examiner death records are both maintained under the Department of Health Services, enhancing the ability of public health researchers to connect these records using matched identifiers. Two years of EMS ambulance run data (2016-2017) were matched to three years of vital death records (2016-2018) that listed opioids as a contributing cause of death. Ambulance runs and death records for individuals aged 10 years or younger were removed from the data prior to matching and were not included in the final analytic set. Records between these two systems were matched using patient first and last name, gender, date of birth, and zip code. Ambulance runs for a suspected opioid overdose were identified by mining text fields from EMS primary and secondary impressions as well as incident narrative details that identified an opioid as a likely cause of the event. Ambulance runs resulting in Narcan/naloxone administration were also identified as opioid-related overdose. Coroner/medical examiner death records that identified opioids as a contributing cause were classified as an opioid-related death. Analyses examining correlates of deaths with opioids as a contributing cause focused on patient demographics, Narcan/naloxone administration rates and dosage, date and time of the ambulance run, lag between EMS response and time of opioid-related death, physical location and urbanicity of the incident, and the type of response by EMS personnel (i.e. treated and transported, treated and released, no treatment, patient refusal, DOA).ResultsFrom 2016-2017, there were over 800,000 emergency ambulance runs among those aged 11 years and older. Opioid overdose ambulance runs accounted for 1.1% (9,761) of those runs. There were over 100,000 deaths in Wisconsin and 1.7% (1,797) were related to opioids (i.e. opioids were a contributing cause). Linking resulted in 268 people with opioid overdose ambulance runs who had an opioid-related death. Of these, 34% died at the scene of the ambulance run, 12% died later that day, 16% died within a week of the ambulance run, and 37% died after a week. While all of these deaths had a contributing cause of opioids, 97% also had an underlying cause of death of drug overdose. Comparing those who died to those who didn’t die, those who died were more likely to be male, younger, and had the event occur on a Saturday. Additionally, while there were no differences in the likelihood of Narcan/naloxone receipt by opioid-related death, individuals who died were more likely to have received multiple Narcan/naloxone doses during the ambulance run than those who did not. Of those who died at the scene, the majority (32%) were aged 30 to 39 years. Of those who died later, the majority (32%) were aged 20 to 29 years. Also, for those who died at the scene, the majority of the events occurred from eight pm to midnight while for those who died later, the majority of events occurred from four to eight pm.ConclusionsThe majority of linked deaths to opioid ambulance runs were due to an underlying cause of drug overdose with opioids as a contributing cause. This demonstrates that the impressions of the EMS personnel were correct. The fact that so many of those who died did so at the scene highlights the continued need for community naloxone distribution. Additionally, there appear to be characteristic differences between those who died, those who died at the scene, and those who didn’t die. The results from this study highlight the benefits of connecting multiple sources of data to facilitate the identification of emergency health care drivers of opioid-related death, but there is still work to be done. Future analyses from this project will seek to link the existing data to hospitalization and post-discharge care records to capture a more complete picture of opioid-related deaths across the entire patient lifecycle. This future work will serve to fill key gaps in the surveillance process, particularly for instances opioid overdose and death where EMS was not called into service. 

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