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Prescription Drug Overdose

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Presentation on theme: "Prescription Drug Overdose"— Presentation transcript:

1 Prescription Drug Overdose
In North Carolina State Health Director’s Meeting Jan 24th, 2014

2 Overview & Surveillance
Agenda Overview & Surveillance Dr. Steve Marshall, UNC Injury Prevention Research Center (IPRC) Legislative Changes (S222 & S20) Elizabeth Hudgins, Child Fatality Task Force (CFTF) Project Lazarus/CCNC-Community Prevention Dr. Robin Cummings, State Health Director 2

3 Epidemiology of the Overdose Problem Personal Stories
Problem Overview Epidemiology of the Overdose Problem Personal Stories What is NC doing? Response Coordination Local ED Surveillance of Overdose CSRS Research at UNC IPRC

4 Disclosures No financial interests or disclosures My partner, Dr. Anna Waller, is associated with the NC-Detect system, which I will be speaking about today

5 Definition – Prescription Drug Overdose
What is a prescription drug overdose? Acute poisoning by prescription medication Opioids or “narcotics” (e.g. hydrocodone, oxycodone, oxymorphone, methadone) Benzodiazepines Any other prescription medication Any substance can become a poison - Dose makes the poison, not the substance The classic definition of a poison by the “Father of Toxicology”, Paracelsus is “All substances are poisons; there is none which is not a poison. The right dose differentiates a poison” or a paraphrased, “the dose makes the poison.” A slightly more updated version used by the Carolinas Poison Center is that a poison can harm someone if used in the wrong way, by the wrong person, or in the wrong amount. For example, aspirin can be a poison if used incorrectly. The phrase “unintentional poisoning” refers to poisonings that are not inflicted by deliberate means (i.e. on purpose) as opposed to assault or self-inflicted injuries.

6 Problem Overview: US Prescription Overdose

7 Pain Management by Medication
Positives Prescription painkillers help people manage chronic pain, greatly improve quality of life Negatives Patient addiction & dependence Diversion of drugs for illicit purposes Overdose

8 15,000 prescription painkiller overdose deaths annually in US
1 in 20 people (>12 yrs) used prescription pain killers for “nonmedical purposes” Enough prescription painkillers were prescribed annually to medicate every US adult around-the-clock for a month November 2011

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10 North Carolina Poisonings Data

11 Unintentional Poisoning and Motor Vehicle Deaths
North Carolina Residents, 1999–2012 Motor Vehicle/Transportation Poisoning National Vital Statistics System, multiple cause dataset Source: Death files , State Center for Health Statistics. Analysis by Injury Epidemiology and Surveillance Unit 11 11 11

12 Unintentional Poisoning Deaths by Drug Type and Year: N. C
Unintentional Poisoning Deaths by Drug Type and Year: N.C. Residents, Note: categories are not mutually exclusive Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, (2012 Provisional) Analysis by Injury Epidemiology and Surveillance Unit 12 12 12

13 Unintentional Poisoning Deaths, 1999-2001
Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, Analysis by Injury Epidemiology and Surveillance Unit

14 Unintentional Poisoning Deaths, 2002-2005
Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, Analysis by Injury Epidemiology and Surveillance Unit 14

15 Unintentional Poisoning Deaths, 2006-2009
Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, Analysis by Injury Epidemiology and Surveillance Unit 15

16 Unintentional Poisoning Deaths, 2010-2012
Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, Analysis by Injury Epidemiology and Surveillance Unit 16

17 Personal Stories: The Polarizing Effect of Drug Abuse
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18 Deadly Pills: A National Epidemic
Kristen Mascia, People Magazine 01/28/2013 Joey DiBernardo Jr, 40 yr old NY firefighter Age 36 yrs: severe occupational injuries jumping from a burning building Cycle of chronic pain, depression, and dependence on prescribed painkillers Expressed deep concern about dependence on medicines Fatal overdose: combined opioid hydromorphone with antidepressant citalopram Not a recreational drug abuser, simply someone trying to live through pain Needed access to information on dangers of combining medicines Photo: New York Daily News

19 Deadly Pills: A National Epidemic
Kristen Mascia, People Magazine 01/28/2013 Harry Cohen, 17 yr old QB, Burlington, NC Took methadone prescribed for a family member with fibromyalgia No reported prior history of drug abuse Classic novice experimenting with drugs Probably limited comprehension of interaction of dosage, tolerance, and body weight Photo:

20 Deadly Pills: A National Epidemic
Kristen Mascia, People Magazine 01/28/2013 “Jace Flom's mom died two weeks after her birth of an overdose of prescription drugs” Photo: Grant Delin

21 Deadly Pills: A National Epidemic
Kristen Mascia, People Magazine 01/28/2013 Melanie Flom, 26 yr old mother Chronic pain from car crash injuries at age 20 Transitioned to a routine recreational drug abuser Fatal overdose event: Combined her prescribed painkillers with other prescription painkillers given to her by friends, plus alcohol Photo: Grant Delin Online comments discuss the perception of addiction as a failure of character, rather than a treatable disorder: “This child is better off without her druggie mom” “Addiction is a choice, not a disease” “Addiction IS a disease, but getting help is a choice”

22 Context for Public Health Prevention Efforts:
Concerns from Pain Patients about Access to Medicine “Articles like this make it harder and harder to get the medication we need to just have a semi-normal day. I, for one, do NOT abuse what is given me.” “Please don't judge those of us who rely on these medications and take them the way they are prescribed …. I have never felt high or impaired on my medication.” “I'm now 34yrs old and have had 6 MAJOR surgeries relating to different diagnoses, starting at the age of 13, I can tell you that without a doubt, I would NOT be able to function, at even a semi-normal level, without a prescription for a strong narcotic.” Photo: Grant Delin Online Comments from Readers on Deadly Pills: A National Epidemic People Magazine 01/28/2013

23 North Carolina’s Response: Coordinating between Partners
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24 Epidemiology, Policy, Partners, Community
North Carolina Injury and Violence Prevention Branch Epidemiology, Policy, Partners, Community Opioid Death Task Force Poisoning Death Study North Carolina Comprehensive Community Approach Chronic Pain Initiative Substance Abuse Policy Policy & Practice Research SAC Poisoning Workgroup Prescription Drug Monitoring System Enforcement SBI & Medical Board Div. of Public Health Drug Take Back Div. Medical Assistance Div. Mental Health/Substance Abuse 24

25 North Carolina’s Response: Take Back Events
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26 Supply and Need Expected duration of pain may be short-term
EG: 2-5 days following surgery Dispensed quantity is often longer EG: 30 days Natural reluctance to throw it away, in case you “need it some day” Result: Gradual accumulation of dangerous medicines in homes

27 Safe Kids and Operation Medicine Drop facilitate safe disposal of medicines in NC

28 Searchable index of community drop-off locations & community take-back events

29 North Carolina’s Response: Realtime ED Surveillance of Drug Overdose in Your County
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30 Deaths vs. ED visits for drug overdose, NC 2011
© 2014 University of North Carolina at Chapel Hill and NC Division of Public Health, NC DHHS Deaths vs. ED visits for drug overdose, NC 2011 1,222 deaths The number of ED visits for overdose dwarfs the number of overdose deaths 22,992 ED visits Average NC county has about one overdose death per month but just under one overdose ED visit per day

31 Unintentional Poisoning ED Visits, 2011
Source: Division of Public Health, NC DETECT-ED visit data, 2011 Analysis by Injury Epidemiology and Surveillance Unit NC DETECT coding for substance abuse, Dx and E-codes as primary 31

32 Local ED surveillance data using NC DETECT
© 2014 University of North Carolina at Chapel Hill and NC Division of Public Health, NC DHHS Local ED surveillance data using NC DETECT NC DETECT was created in 2004 to address the need for timely detection of public health emergencies. In 2005, under NC General Statute § 130A-480, all 24/7, acute-care, hospital-affiliated EDs were required to submit ED visit data every 12 hours. In addition to ED visit data, NC DETECT captures data from the Carolinas Poison Center (CPC), the Pre-hospital Medical Information System (PreMIS), four VA Medical Center EDs, and select urgent care centers. NC DETECT was created in the wake of 9/11 and the anthrax attack of Its initial focus was the use of syndromic surveillance for the detection of public health emergencies. NC DETECT is still used for these purposes, but it is now has a much broader public health function. All 24/7, acute-care, hospital-affiliated EDs are required to submit their ED visit data within 12 hours. The initial data submission is often missing final diagnosis and injury codes. The codes are tied to hospital billing and so may arrive up to three months later.

33 NC DETECT Overdose Surveillance
© 2014 University of North Carolina at Chapel Hill and NC Division of Public Health, NC DHHS NC DETECT Overdose Surveillance 4 reports currently available on Hot Topics Dashboard & Custom Event Line Listing 9 additional to be added soon Graphs, line listing information available ZIP code maps for select reports by June

34 Dashboard of Overdose Reports For Your County
© 2014 University of North Carolina at Chapel Hill and NC Division of Public Health, NC DHHS Dashboard of Overdose Reports For Your County

35 Opioid OD Graph from NC DETECT
© 2014 University of North Carolina at Chapel Hill and NC Division of Public Health, NC DHHS Opioid OD Graph from NC DETECT © 2014 University of North Carolina at Chapel Hill and NC Division of Public Health, NC DHHS

36 Report on Opioid Analgesic Overdose ED Visits for Your County
© 2014 University of North Carolina at Chapel Hill and NC Division of Public Health, NC DHHS Report on Opioid Analgesic Overdose ED Visits for Your County Age Group Sex Chief Complaint Triage Note XX Overdose Chief Complaint Subjective: Per EMS, wife last saw normal, woke up and found him on the couch with agonal breathing. When EMS arrive, gave Narcan. Patient awake and cooperative at this time. DRUG OVERDOSE denies suicide, crushed and injected XXX pt states took 5 XXXX around XX. pt appears sleepy. pt A+O x4. pt denies SI states she was hurting in neck and back. EMS states …. OVERDOSE per ems pt from home poss od on ambien, xanax and neurontin, ems sts blood sugar on scene, ems sts pt was last found normal approx XXX © 2014 University of North Carolina at Chapel Hill and NC Division of Public Health, NC DHHS

37 http://www.ncdetect.org/ Account Request
© 2014 University of North Carolina at Chapel Hill and NC Division of Public Health, NC DHHS Account Request

38 © 2014 University of North Carolina at Chapel Hill and NC Division of Public Health, NC DHHS
NC DETECT Training Contact Jenna Waggoner or Amy Ising for customized Web-based or in-person training (919) NC DETECT User Guide available online Help icon on dashboard reports

39 NC Controlled Substance Reporting System (CSRS)
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40 Controlled Substance Reporting System
Allows a healthcare provider to review complete prescription history for a patient Including prescriptions from other providers Excellent idea, but not used by all providers Legislative committees to study the CSRS Legislative bills to strengthen the CSRS Invaluable information for public health monitoring and analysis of provider prescribing

41 Source: Substance Abuse and Mental Health Services Administration
Source: Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings. Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies; 2013.

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43 UNC IPRC Overdose Research
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44 UNC IPRC Research Funding: Research Topics include Evaluating:
CDC, NIJ, Kate B. Reynolds Foundation Research Topics include Evaluating: ED protocols for managing pain patients Effectiveness of the CSRS in NC and similar programs nationally Project Lazarus and Chronic Pain Initiative Surveillance Methodologies Identification of Select Health Care Providers Medicaid’s Lock-In Program

45 Acknowledgements IVPB / DPH: Scott Proescholdbell NC-Detect / DPH:
Katie Harmon, Amy Ising, Lana Deyneka, many others UNC: Chris Ringwalt, Mariana Garrettson, Nabarun Dasgupta Others: Fred Brason, Kay Sanford

46 Thank you! injuryfreenc.org iprc.unc.edu Steve Marshall, PhD
Injury Research Prevention Center (IPRC) & Gillings School of Global Public Health University of North Carolina-Chapel Hill injuryfreenc.org iprc.unc.edu


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