ACOPC Allegheny County Overdose Prevention Coalition Presents

PERMEATING BORDERS

OVERDOSE PREVENTION Summer Conference 2014

July 24, 2014

ACOPCAllegheny County Overdose Prevention Coalition

Presents

The Overdose Problem in Allegheny County

Karl Williams MD, MPHChief Medical Examiner

Allegheny County

The Overdose Problem in Allegheny County

2008-2014

Allegheny CountyOverdose Prevention

CoalitionSummer Conference

July 24, 2014

Karl E. Williams, MD MPHChief 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 Relieversand 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.

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 20120

50

100

150

200

250

300

350

Overdose Deaths (By Year)

CASES

Scope of Problem in Allegheny County2012

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

2008 2009 2010 2011 2012 20130.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

56.63% 57.99% 58.06%60.37%

64.59% 63.33%

20.80%19.17% 19.62%

22.18%25.48%

23.58%

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

ACOME Drug Deaths by Age Group

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 >0.00%2.00%4.00%6.00%8.00%

10.00%12.00%14.00%16.00%18.00%20.00%

2.97%

9.75% 9.32%

5.08%

8.90%

16.10%

18.64%

15.68%

9.32%

2.54% 1.69%

2008 % of Drug Deaths per Age Group

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 >0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

3.13%6.25%

10.27% 10.71%9.38%

11.16%

16.07%19.20%

9.38%

3.57%0.89%




10.00%12.00%14.00%16.00%18.00%20.00%

1.76%

6.61%

11.01% 10.57%8.81%

12.78%14.10%

17.18%

11.01%

4.41%

1.76%



10.00%12.00%14.00%16.00%18.00%

3.14%

5.83%

11.66%

8.07%

10.31%

13.45%15.25%

17.04%

10.31%

4.04%

0.90%




10.00%12.00%14.00%16.00%18.00%20.00%

0.69%

8.33%

15.97% 16.67%

7.64% 7.29%

11.81%

17.71%

8.33%

5.21%

0.35%



2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

16.00%

18.00%

2.29%

6.11%

11.45%12.60% 12.21%

13.36%

16.79%

13.74%

7.25%

4.20%


Drug Death per Age Group


2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

16.00%

2.16%

5.40%

9.35%

15.11%

12.23%

11.15%

14.03%

11.15%

12.95%

6.47%


ACOME Drug Deaths by Race/Sex

White Black Other0

20406080

100120140 131

28

2

57

5

2009 Drug Deaths by Race / SexMale Female

White Black Other0

20406080

100120140 124

28

1

63

11


ACOME Drug Deaths by Race/Sex

White Black Other0

20406080

100120140160 151

264

93

131


White Black Other0

20406080

100120140160 152

201

76

13


Drug Death by Race/Sex in 2013

White Black Other0

20

40

60

80

100

120

140

160

180

161

27

2

81

7

2013 Drug Deaths by Race / Sex

Male Female

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

Legend

Allegheny County 2000 Census Tracts

Pittsburgh City Boundary

Distressed Ranking

Distressed - Meeting Three Criteria

Distressed - Meeting Four Criteria

Severely Distressed Neighborhoods

Percentage of population below 100% of the federal poverty line

Percentage of families headed by single females

Percentage of youth ages 16 to 19 without a high school diploma or equivalent, and not enrolled in school

Percentage of civilian males ages 16-64 who are unemployed or not in the labor force

Threshold = One standard deviation above the mean

The Growing Number of Kids in Severely Distressed Neighborhoods: Evidence from the 2000 CensusBy William O. Hare and Mark MatherOctober 2003Annie E. Casey Foundation, Population Reference Bureau

McKeesport

Duquesne

McKees Rocks

Homewood

Community Need Index(measuring relative need)

* All indicators are Census variables measured as percentages† Indicators included in Hare and Mather’s criteria for severely distressed neighborhoods

• 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

Community Need Index – Full County

McKeesport

McCandlessTarentum

McKees Rocks

Clairton

Penn Hills

Braddock

Brentwood

Baldwin

CarnegieMonroeville

Bridgeville

Coraopolis

Millvale

Forward

ComparisonNEW METHOD

Communities Outside the City (Top 50% with Highest Level of

Need)

OLD METHOD

Population Below Federal Poverty Line, 2005-2009

Legend

Pittsburgh_City_Limits

Percent Below Poverty Line

< 7.6%

7.7 - 16.8%

16.9 - 30.4%

30.5 - 48.9%

> 48.9%

Allegheny CountyPercent of Population Below the Federal Poverty Line, 2005-2009

Zoom

Legend

City of Pittsburgh

Allegheny County Municipalities

Community Need Index

Low Need (0 - 49th percentile)

Moderate Need (50 - 59th percentile)

Moderate Need (60 - 69th percentile)

High Need (70 - 79th percentile)

Very High Need (80 - 89th percentile)

Distressed (90 - 100th percentile)

ComparisonOLD METHOD

Population Below Federal Poverty Line, 2005-2009

Penn Hills Penn Hills

McKeesport McKeesport

Braddock

WilkinsburgWilkinsburg

Braddock

Homewood

Duquesne Duquesne

Homestead HomesteadPitcairn Pitcairn

NEW METHOD

Communities Outside the City (Top 50% with Highest Level of

Need)

Overdose by Location - 1

Overdose by Home (Residence) Address

Overdose by Location - 2

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 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 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

Heroin; 138

Alcohol; 72Cocaine; 67

Alprazolam; 36

Morphine; 31

Oxycodone; 31

Oxymorphone; 26

Methadone; 21

2012 Top 8 Drugs FoundSingle or Combined OD

HeroinAlcoholCocaineAlprazolamMorphineOxycodoneOxymorphoneMethadone

Top Eight Drugs Found in Overdose Deaths

Cocaine; 86

Alcohol; 56

Heroin; 50Morphine; 48

Oxycodone; 40

Alprazolam; 39

Methadone; 32

Diazepam; 20


CocaineAlcoholHeroinMorphineOxycodoneAlprazolamMethadoneDiazepam

Cocaine; 76

Heroin; 63

Alcohol; 61Morphine;

40

Alprazo-lam; 39

Methadone; 38

Oxy-codone; 33Hydrocodone; 25


CocaineHeroinAlcoholMorphineAlprazolamMethadoneOxycodoneHydrocodone

Heroin; 138

Alcohol; 72Cocaine; 67

Alprazo-lam; 36

Morphine; 31

Oxy-codone; 31

Oxymor-phone; 26Methadone; 21


HeroinAlcoholCocaineAlprazolamMorphineOxycodoneOxymorphoneMethadone

Heroin; 95

Cocaine; 83

Alcohol; 60

Oxycodone; 51

Alprazolam; 42

Methadone; 26

Diazepam; 25

Morphine; 24


HeroinCocaineAlcoholOxycodoneAlprazolamMethadoneDiazepamMorphine

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

38.57%

0.71%

60.71%

2012

% Heroin Only% Heroin/Fen-tanyl in Com-bined Overdose% Heroin Other Combined Overdose

32.88%

67.12%

2013

% Heroin Only% Heroin/Fen-tanyl in Com-bined Overdose% Heroin Other Combined Overdose

2014 Heroin/Fentanyl Crisis

31.25%

20.31%

48.44%

2014 Heroin Deaths

% Heroin Only

% Heroin/Fentanyl in Combined Overdose

% Heroin Other Combined Overdose

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

ACOPC Allegheny County Overdose Prevention Coalition Presents

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