Download ACOPC Allegheny County Overdose Prevention Coalition Presents

ACOPC
Allegheny County Overdose Prevention Coalition
Presents
PERMEATING
BORDERS
OVERDOSE PREVENTION
Summer Conference 2014
July 24, 2014
The Overdose Problem in
Allegheny County
Karl Williams MD, MPH
Chief Medical Examiner
Allegheny County
The Overdose Problem in
Allegheny County
2008-2014
Allegheny County
Overdose Prevention
Coalition
Summer Conference
July 24, 2014
Karl E. Williams, MD MPH
Chief Medical Examiner
Allegheny County
Scope of the National Problem
• In 2007, approximately 27,000 unintentional overdose deaths
occurred in the U.S., one death every 19 minutes (MMWR,
January 13, 2013)
• Rate of unintentional overdose deaths in the U.S. has been
steadily increasing, largely attributed to prescription drug
abuse
Historical Trend
Scope of the National Problem
• Prescription drug abuse is the fastest growing drug problem in
the U.S.
• Since 2003, more overdose deaths have involved opioid
analgesics than heroin or cocaine combined
OD vs Other Causes
Unintentional Drug Overdose Deaths
in U.S. during 1999-2007
Opioid Production and Consequences
Overdoses of Prescription Opioid Pain Relievers
and Other Drugs Among Women–U.S., 1999-2010
Reported in Morbidity and Mortality Weekly July 5, 2013
• Overdose deaths increasing steadily
• In 2012, total of 15,323 deaths among women
were attributed to drug overdoses
• Opiate pain reliever (OPR) deaths increased five
fold between 1999 -2010 for women
• OPR deaths among men increased 3.6 times
• Conclusion: More men die from drug overdoses
than women, however % increase in deaths since
1999 is greater for women
Crude rates for drug overdose deaths and drug
misuse-or abuse-related emergency department
visit among women by select drug class
Medical Examiner Data
(2002 - 2012)
• According to the Allegheny County Medical Examiner’s Office, there have
been approximately 2,847 overdose deaths in Allegheny County between
January 1, 2002 and December 31, 2012.
• On average, there were 259 cases reported each year during this time
period.
Overdose Deaths (By Year)
350
300
250
200
CASES
150
100
50
0
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Scope of Problem in Allegheny County
2012
ACOME Death Investigations:
• Total Number of cases: 1138
• Accidental Deaths: 446 (39.1%)
• Unintentional Drug Deaths: 288 (25.31%)
• Unintentional Drug Deaths as % of Accidental
Deaths: 64.5%
ACOME Drug Deaths as % of
Morgue and Accidental Cases
70.00%
64.59%
60.00%
56.63%
57.99%
58.06%
63.33%
60.37%
50.00%
40.00%
30.00%
25.48%
20.80%
20.00%
22.18%
19.17%
23.58%
19.62%
10.00%
0.00%
2008
2009
2010
Drug Deaths as % Accidental Deaths
2011
2012
Drug Death as % All Morgue Cases
2013
ACOME Drug Deaths by Age Group
2007 % of Drug Deaths per Age Group
25.00%
19.20%
20.00%
16.07%
15.00%
10.27%
10.00%
5.00%
10.71%
9.38%
11.16%
9.38%
6.25%
3.57%
3.13%
0.89%
0.00%
0 thru 19
20 thru 24
25 thru 29
30 thru 34
35 thru 39
40 thru 44
45 thru 49
50 thru 54
55 thru 59
60 thru 69
70 or >
2008 % of Drug Deaths per Age Group
18.64%
20.00%
16.10%
15.68%
15.00%
9.75%
10.00%
9.32%
9.32%
8.90%
5.08%
5.00%
2.97%
2.54%
1.69%
0.00%
0 thru 19
20 thru 24
25 thru 29
30 thru 34
35 thru 39
40 thru 44
45 thru 49
50 thru 54
55 thru 59
60 thru 69
70 or >
ACOME Drug Deaths by Age Group
2009 % of Drug Deaths per Age Group
18.00%
16.00%
14.00%
12.00%
10.00%
8.00%
6.00%
4.00%
2.00%
0.00%
17.04%
15.25%
13.45%
11.66%
10.31%
10.31%
8.07%
5.83%
4.04%
3.14%
0.90%
0 thru 19
20 thru 24
25 thru 29
30 thru 34
35 thru 39
40 thru 44
45 thru 49
50 thru 54
55 thru 59
60 thru 69
70 or >
2010 % of Drug Deaths per Age Group
20.00%
17.18%
15.00%
12.78%
11.01%
14.10%
11.01%
10.57%
8.81%
10.00%
6.61%
4.41%
5.00%
1.76%
1.76%
0.00%
0 thru 19
20 thru 24
25 thru 29
30 thru 34
35 thru 39
40 thru 44
45 thru 49
50 thru 54
55 thru 59
60 thru 69
70 or >
ACOME Drug Deaths by Age Group
2011 % of Drug Deaths per Age Group
16.79%
18.00%
16.00%
14.00%
11.45%
12.00%
12.60%
12.21%
13.74%
13.36%
10.00%
8.00%
7.25%
6.11%
6.00%
4.00%
4.20%
2.29%
2.00%
0.00%
0 thru 19
20 thru 24
25 thru 29
30 thru 34
35 thru 39
40 thru 44
45 thru 49
50 thru 54
55 thru 59
60 thru 69
70 or >
2012 % of Drug Deaths per Age Group
20.00%
18.00%
16.00%
14.00%
12.00%
10.00%
8.00%
6.00%
4.00%
2.00%
0.00%
15.97%
17.71%
16.67%
11.81%
8.33%
7.64%
8.33%
7.29%
5.21%
0.69%
0 thru 19
0.35%
20 thru 24
25 thru 29
30 thru 34
35 thru 39
40 thru 44
45 thru 49
50 thru 54
55 thru 59
60 thru 69
70 or >
Drug Death per Age Group
2013 % of Drug Deaths per Age Group
16.00%
15.11%
14.03%
14.00%
12.95%
12.23%
12.00%
11.15%
10.00%
11.15%
9.35%
8.00%
6.47%
6.00%
5.40%
4.00%
2.16%
2.00%
0.00%
0 thru 19
20 thru 24
25 thru 29
30 thru 34
35 thru 39
40 thru 44
45 thru 49
50 thru 54
55 thru 59
60 thru 69
70 or >
ACOME Drug Deaths by Race/Sex
2009 Drug Deaths by Race / Sex
Male
150
Female
131
100
57
50
28
5
2
0
White
Black
Other
2010 Drug Deaths by Race / Sex
Male
150
Female
124
100
63
50
28
11
1
0
White
Black
Other
ACOME Drug Deaths by Race/Sex
2011 Drug Deaths by Race / Sex
Male
Female
200
152
150
100
76
50
20
13
1
0
White
Black
Other
2012 Drug Deaths by Race / Sex
Male
Female
200
151
150
93
100
50
26
13
4
1
0
White
Black
Other
Drug Death by Race/Sex in 2013
2013 Drug Deaths by Race / Sex
Male
Female
180
161
160
140
120
100
81
80
60
40
27
20
7
2
0
White
Black
Other
Drug Death by Race/Sex in 2012
• White males accounted for highest % of
deaths (52.4%)
• White females accounted for 32.2% in 2012
• Number of white females increasing:
2011: 29%
2010: 27%
• Other races, both M and F accounted for
15.2% of deaths
Examining Community Distress
Severely Distressed Neighborhoods
 Percentage of population below 100% of
the federal poverty line
 Percentage of families headed by single
females
McKees Rocks
 Percentage of youth ages 16 to 19
without a high school diploma or
equivalent, and not enrolled in school
Homewood
 Percentage of civilian males ages 16-64
who are unemployed or not in the labor
force
Duquesne
McKeesport
Threshold = One standard deviation above the mean
Legend
Allegheny County 2000 Census Tracts
The Growing Number of Kids in Severely Distressed
Neighborhoods: Evidence from the 2000 Census
By William O. Hare and Mark Mather
October 2003
Annie E. Casey Foundation, Population Reference Bureau
Pittsburgh City Boundary
Distressed Ranking
Distressed - Meeting Three Criteria
Distressed - Meeting Four Criteria
Community Need Index
(measuring relative need)
• Population below 100% of the federal poverty line†
• Families headed by single females†
• Youth ages 16 to 19 without a high school diploma or equivalent,
and not enrolled in school†
• Civilian males ages 16-64 who are unemployed or not in the
labor force†
• Population below 200% of the federal poverty line
• Houses vacant
• Households with no available vehicle
* All indicators are Census variables measured as percentages
† Indicators included in Hare and Mather’s criteria for severely distressed neighborhoods
Community Need
Index – Full County
McCandless
Tarentum
Coraopolis
McKees Rocks
Millvale
Penn Hills
Monroeville
Carnegie
Bridgeville
Braddock
Brentwood
Baldwin
Clairton
Forward
McKeesport
Comparison
OLD METHOD
NEW METHOD
Population Below Federal
Communities Outside the City
(Top 50% with Highest Level of
Need)
Allegheny County
Percent of Population
Below
the 2005-2009
Federal Poverty Line, 2005-2009
Poverty
Line,
Zoom
Legend
Pittsburgh_City_Limits
Percent Below Poverty Line
< 7.6%
7.7 - 16.8%
16.9 - 30.4%
30.5 - 48.9%
> 48.9%
Comparison
OLD METHOD
Population Below Federal
Poverty Line, 2005-2009
NEW METHOD
Communities Outside the City
(Top 50% with Highest Level of
Need)
Penn Hills
Penn Hills
Homewood
Wilkinsburg
Wilkinsburg
Pitcairn
Homestead
nd
City of Pittsburgh
Braddock
Pitcairn
Homestead
Braddock
Duquesne
Duquesne
McKeesport
McKeesport
Overdose by Location - 1
Overdose by Location - 2
Overdose by Home (Residence)
Address
Top Ten Tracts by Residence Rate
(2002 - 2012)
Name
Tracts
Incidents
Population
Rate
Chalfant Borough
Census Tract 5639
9
800
11.3
Hays
Census Tract 5629
21
1926
10.9
McDonald Borough
Census Tract 5640
4
383
10.4
Lower Lawrenceville
Census Tract 603
20
2341
8.5
Bloomfield
Census Tract 903
13
1629
8.0
Polish Hill
Census Tract 605
10
1274
7.8
Dormont Borough
Census Tract 4721
19
2524
7.5
Mount Washington
Census Tract 1915
15
2047
7.3
Clairton City
Census Tract 4927
13
1882
6.9
Allentown
Census Tract 1803
17
2500
6.8
Top Ten Tracts by Incidents
(2002 - 2012)
Name
Tracts
Incidents
Terrace Village
Census Tract 402*
88
Bluff
Census Tract 103*
46
Monroeville Municipality
Census Tract 5214.01*
28
Shadyside
Census Tract 709
28
McKeesport City
Census Tract 5519
27
Kennedy Township
Census Tract 4600.02
26
Central Business District
Census Tract 201
25
O'Hara Township
Census Tract 4240
24
Beechview
Census Tract 1916
23
Brookline
Census Tract 1918
22
*Hospital addresses are commonly given as incident addresses – the majority of the above
counts reflect treatment locations not residence location of the individuals.
Top Ten Tracts by Residence Rate
(2002 - 2012)
Name
Tracts
Incidents
Population
Rate
Chalfant Borough
Census Tract 5639
9
800
11.3
Hays
Census Tract 5629
21
1926
10.9
McDonald Borough
Census Tract 5640
4
383
10.4
Lower Lawrenceville
Census Tract 603
20
2341
8.5
Bloomfield
Census Tract 903
13
1629
8.0
Polish Hill
Census Tract 605
10
1274
7.8
Dormont Borough
Census Tract 4721
19
2524
7.5
Mount Washington
Census Tract 1915
15
2047
7.3
Clairton City
Census Tract 4927
13
1882
6.9
Allentown
Census Tract 1803
17
2500
6.8
Other Observations
(2002 - 2012)
• 91% of the deaths were ruled as accidental.
• Around 65% of the time, the incident occurred in the individual’s home.
• The number of overdoses remained rather steady over the course of
year but occurred most frequently in December (9%) and May (8.9%)
and least frequently in October (7.6%) and November (7.4%).
ACOME Drug Deaths Total
Single 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 Drug Deaths
• Most drug deaths involve multiple drugs
(61%> 1 drug)
• Single drug deaths in 2008-2010 attributed to
cocaine, heroin or alcohol
• Alcohol listed on death certificate on 18-24%
of drug deaths in 2008-2010
• Cocaine and heroin common co intoxicants
• Benzodiazepines often found with opiates
2012 Top 8 Drugs Found
• Heroin most prevalent, identified in 47.9% of overdose deaths
•
Alcohol:
25.0 %
•
Cocaine:
23.2 %
•
Alprazolam:
12.5 %
•
Oxycodone:
10.7 %
•
Morphine :
10.7 %
•
Oxymorphone:
9.0 %
•
Methadone:
7.2 %
•
Hydrocodone (5.2%), Codeine (3.8%), and Fentanyl(4.8%) not as prevalent
•
Low incidence of amphetamine, methamphetamine and other designer
drugs (<1%)
ACOME Accidental Overdose Cases
2012 Top 8 Drugs Found
Single or Combined OD
Methadone, 21
Oxymorphone, 26
Oxycodone, 31
Heroin, 138
Heroin
Alcohol
Cocaine
Morphine, 31
Alprazolam
Morphine
Oxycodone
Oxymorphone
Alprazolam, 36
Methadone
Cocaine, 67
Alcohol, 72
Top Eight Drugs Found in Overdose Deaths
2012 Top 8 Drugs Found
2011 Top 8 Drugs Found
Single or Combined OD
Single or Combined OD
Methadone,
Oxymorphon 21
e, 26
Oxycodone,
31
Heroin
Heroin, 138
Alcohol
Morphine, 24
Diazepam, 25
Methadone,
26
Heroin, 95
Cocaine
Cocaine
Morphine, 31
Alprazolam
Morphine
Alprazolam,
36
Alcohol
Alprazolam,
42
Oxycodone
Alprazolam
Oxycodone
Oxymorphone
Alcohol, 72
Cocaine, 67
Methadone
Methadone
Morphine
2009 Top 8 Drugs Found
Single or Combined OD
Cocaine
Hydrocodone,
Oxycodone, 25
33
Cocaine, 76
Alcohol
Alprazolam,
39
Heroin
Morphine
Alcohol, 56
Alprazolam
Methadone
Morphine, 48
Heroin, 50
Diazepam
Cocaine
Heroin
Methadone,
38
Alcohol
Morphine
Oxycodone
Oxycodone,
40
Diazepam
Alcohol, 60
Single or Combined OD
Cocaine, 86
Cocaine, 83
Oxycodone,
51
2010 Top 8 Drugs Found
Methadone, Diazepam, 20
32
Heroin
Heroin, 63
Alprazolam,
39
Morphine, 40
Alprazolam
Methadone
Oxycodone
Alcohol, 61
Hydrocodone
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
Heroin & Fentanyl
Heroin/Fentanyl Cases
2012
2013
% Heroin Only
% Heroin Only
38.57%
60.71%
0.71%
%
Heroin/Fentanyl
in Combined
Overdose
% Heroin Other
Combined
Overdose
32.88%
67.12%
0.00%
%
Heroin/Fentanyl
in Combined
Overdose
% Heroin Other
Combined
Overdose
2014 Heroin/Fentanyl Crisis
2014 Heroin Deaths
% Heroin Only
31.25%
48.44%
% Heroin/Fentanyl in Combined
Overdose
% Heroin Other Combined Overdose
20.31%
Heroin: bricks, bundles, stamp bags…
Summary
• Heroin is responsible for greatest percentage of overdose
deaths in Allegheny County.
• Oxycodone and oxymorphone identified in 19.7% of overdose
deaths.
• The number of overdose deaths in the 20-34 year old age
category is increasing.
• Pittsburgh has a “traditional pattern” of drug use.
Acknowledgements
• Jennifer Janssen, Department of Labs, ACOME
• Erin Dalton, Department of Human
Services/Allegheny County
• Kristen Mertz, MD, MPH – Department of
epidemiology/GSPH/University of Pittsburgh
• Patricia Rekiel – Computer Analyst, ACOME