NC DHHS Injury and Violence Prevention Branch, 10/27/ A Public Health Response to an Epidemic of Fatal Drug Overdoses in North Carolina Catherine (Kay) Sanford, MSPH Injury and Violence Prevention Branch Division of Public Health, NC-DHHS

NC DHHS Injury and Violence Prevention Branch, 10/27/ NC’s Public Health Steps 1. CDC-NCIPC Injury Indicator Report 2. EIS Investigation – Fatal Poisonings in NC 3. Task Force on Unintentional Drug Overdoses 4. MMWR on Unintentional Drug Overdoses in 11 states 5. Task Force Recommendations 6. NC-DOJ/DHHS Leadership Committee on Drug Overdoses 7. Year 1: Surveillance and PMP Legislation

NC DHHS Injury and Violence Prevention Branch, 10/27/ CDC-NCIPC Injury Indicator Report 1.NC Division of Public Health Injury and Violence Prevention Branch funded through CDC’s “Core Capacity” program in In , NC Injury Program participated in first national Injury Indicator Report; approx. 20 states, using 1999 data.

NC DHHS Injury and Violence Prevention Branch, 10/27/2005 4

NC DHHS Injury and Violence Prevention Branch, 10/27/ Definition of Poisoning Damaging physiologic effects from exposure to –pharmaceuticals (prescribed and OTC) –illicit drugs (e.g., cocaine, heroin) –chemicals (e.g., pesticides) –heavy metals (e.g., mercury) –gases/vapors (e.g., carbon monoxide) –household substances (e.g, bleach, ammonia)

NC DHHS Injury and Violence Prevention Branch, 10/27/ Accidental Drug Overdose - International Classification of Disease (ICD) Definition Unintentional (Accidental) Drug Overdose –Inaccurate prescription or administration of a drug/substance –Inappropriate consumption of a drug/substance

NC DHHS Injury and Violence Prevention Branch, 10/27/ Adverse Effect from Drug- International Classification of Disease (ICD) Definition Adverse Effect(s) from a Drug –Appropriate prescription/administration of drug with the patient experiencing an adverse physiologic reaction to the drug/substance.

NC DHHS Injury and Violence Prevention Branch, 10/27/ Comparing NC injury trends to that of the nation. Intentional and Unintentional Poisoning Crude Death Rates in the US and NC: WISQARS:

NC DHHS Injury and Violence Prevention Branch, 10/27/ NC Resident Deaths Due to Poisoning by Manner/Intent: 1997 – 2001

NC DHHS Injury and Violence Prevention Branch, 10/27/ EIS Investigation – ? Epidemic of Fatal Poisonings in North Carolina 1.Mortality data showed clear evidence that increase in deaths was due to unintentional poisonings. 2.NC State Health Director requested an EIS investigation from CDC 3.June-July 2002: Review of 1,096 Medical Examiner cases in 3 weeks 4.Confirmation on Indicator Report findings

NC DHHS Injury and Violence Prevention Branch, 10/27/ Case Definition: Underlying cause of death from Medical Examiner –Underlying cause was drug-related based on impression of ME on investigation report, and review by pathologists and toxicologists at OCME: autopsy, toxicology report, review of clinical and historical information. –M. E. concluded manner of death was accidental

NC DHHS Injury and Violence Prevention Branch, 10/27/ Case Definition for Reviewing Medical Examiner Cases of Accidental Drug Overdose Deaths Initial Selection: all NC residents dying in NC between 1997 and 2001, inclusive, with an underlying cause of death due to unintentional drug-related poisoning (E850- E858; X40-X44) with a death certificate on file at the NC State Center for Health Statistics.

NC DHHS Injury and Violence Prevention Branch, 10/27/ ME Chart Abstraction ME Abstraction % of VS Vital Stats

NC DHHS Injury and Violence Prevention Branch, 10/27/ Deaths from Unintentional Drug Overdoses from NC ME Data (n=1,096) by Age and Sex :

NC DHHS Injury and Violence Prevention Branch, 10/27/ Unintentional Drug Deaths by Race from Abstracted ME Records (N=1096) in NC:

NC DHHS Injury and Violence Prevention Branch, 10/27/ Unintentional Drug Deaths by Sex from Abstracted ME Records (N=1096) in NC: Males: N= % Females: N= %

NC DHHS Injury and Violence Prevention Branch, 10/27/ Unintentional Drug Deaths by Sex and Year from Abstracted ME Records (N=1096) in NC: Males: 66% increaseFemales: 210% increase Males: 66% increase Females: 210% increase

NC DHHS Injury and Violence Prevention Branch, 10/27/

NC DHHS Injury and Violence Prevention Branch, 10/27/ Treatment Provided Prior to Deaths from Unintentional Drug Overdoses from Medical Examiner Data in North Carolina: DOA = dead on arrival ED = emergency department Rx = treatment (1,096 ME cases)

NC DHHS Injury and Violence Prevention Branch, 10/27/ Unintentional Drug Deaths by Past Medical History from Abstracted ME Records (N=1096) in NC: %Mental Health 20.1%Chronic Pain 23.8%Alcohol Abuse/Alcoholism 53.8%Drug Abuse

NC DHHS Injury and Violence Prevention Branch, 10/27/ Decedents’ Source of Drugs from NC Medical Examiner Records by Sex :

NC DHHS Injury and Violence Prevention Branch, 10/27/ Deaths Resulting From a Single Drug by Type and Sex, NC Medical Examiner Records:

NC DHHS Injury and Violence Prevention Branch, 10/27/ Unintentional Deaths from a Single Drug: Illicit Drugs, North Carolina,

NC DHHS Injury and Violence Prevention Branch, 10/27/ Unintentional Deaths from a Single Drug: Licit Drugs North Carolina,

NC DHHS Injury and Violence Prevention Branch, 10/27/ Unintentional Deaths from Multiple Drugs: North Carolina, No. deaths = 316

NC DHHS Injury and Violence Prevention Branch, 10/27/ % 729% 93% % change from 97 to Number Change 88.1%12832All Rx Narcotics 46.7%587Methadone All Poisoning deaths % of overall increase Deaths Resulting From a Single Drug (n=780): Change from 1997 to 2001

NC DHHS Injury and Violence Prevention Branch, 10/27/ Why Methadone? Relatively effective AND cheap analgesic; Reluctance of some MD’s to prescribe other synthetic opioids (e.g., oxycodone); Relatively few side effects; no euphoria - The Catch 22 Very long half-life; Idiosyncratic metabolism; requires careful follow-up first couple of weeks.

NC DHHS Injury and Violence Prevention Branch, 10/27/ The Source of the Methadone? Probably not the OTP clinics-diversion not thought to be prevalent in NC; Likely diversion from prescriptions for abuse - recreation or to compensate for no heroin; Likely misuse for pain management.

NC DHHS Injury and Violence Prevention Branch, 10/27/ Creation of Task Force on Unintentional Drug Overdoses Created by Secretary of NC-DHHS, Nov Mission: study epidemic and develop recommendations to identify, reduce and ultimately prevent unintentional deaths from the use of illicit and licit drugs.

NC DHHS Injury and Violence Prevention Branch, 10/27/ Medical Practice Pharmacy Co-chaired by State Epidemiologist and Ass’t Director SBI Substance Abuse Services Medical Examiners Toxicology State and Federal Law Enforcement Epidemiologic Surveillance Public Health Injury Prevention Specialists Law and Criminal Justice North Carolina Task Force to Prevent Deaths from Unintentional Drug Overdoses Mental Health

NC DHHS Injury and Violence Prevention Branch, 10/27/ Results of Task Force to Prevent Deaths from Unintentional Drug Overdoses Met for 15 months. Report sent to DHHS and DOJ, April Findings described an increasing epidemic of deaths from unintentional drug overdoses in NC. 48 Recommendations to prevent or mitigate deaths: –State infrastructure to focus on prevention; surveillance, law enforcement, legislation, education for professionals, education for public, and clinical intervention.

NC DHHS Injury and Violence Prevention Branch, 10/27/ Three Dimensional Haddon Matrix Adapted from Runyan, CW. Injury Prevention, 1998(4),

NC DHHS Injury and Violence Prevention Branch, 10/27/ MMWR on Unintentional Drug Overdoses in 11 states 1.Concomitant research within the state and with other states on increases in unintentional drug- related deaths. 2.Findings continued to support increasing deaths. 3. Published MMWR: March 26, 2004 (vol.53#11).

NC DHHS Injury and Violence Prevention Branch, 10/27/ Task Force Recommendations Submitted to Secretary of NC-DHHS and Attorney General of NC-DOJ, April recommendations: no defeats; never more than one “no” vote; primary objections from pharmacy representatives. Harm Reduction could not be included due to funding constraints.

NC DHHS Injury and Violence Prevention Branch, 10/27/ NC Drug Task Force Recommendations 1.LEADERSHIP recommendations create a joint DHHS and DOJ leadership structure for oversight of all surveillance, intervention and enforcement activities related to preventing unintentional drug overdoses.

NC DHHS Injury and Violence Prevention Branch, 10/27/ NC Drug Task Force Recommendations 2.SURVEILLANCE recommendations compile and monitor data relevant to unintentional overdoses that are provided to the DHHS/DOJ Leadership Committee at least four times a year.

NC DHHS Injury and Violence Prevention Branch, 10/27/ NC Drug Task Force Recommendations 3.LAW ENFORCEMENT recommendations provide infrastructure to prevent illegal distribution and use of controlled medications.

NC DHHS Injury and Violence Prevention Branch, 10/27/ NC Drug Task Force Recommendations 4.LEGISLATIVE INITIATIVE recommendations create requirements and regulations necessary to implement surveillance activities, create fines to help finance the system and improve access to treatment services.

NC DHHS Injury and Violence Prevention Branch, 10/27/ NC Drug Task Force Recommendations 5.EDUCATIONAL INTERVENTIONS – GENERAL PUBLIC recommendations to raise public awareness about the magnitude, risks and signs of unintentional overdose, preventive behaviors and precautions, and available emergency treatment and law enforcement resources.

NC DHHS Injury and Violence Prevention Branch, 10/27/ NC Drug Task Force Recommendations 6.EDUCATIONAL INTERVENTIONS – PROFESSIONALS recommendations to raise professional awareness about the magnitude, risks and signs of unintentional overdose and create practice guidelines and educational and credentialling requirements for prevention, treatment and enforcement activities.

NC DHHS Injury and Violence Prevention Branch, 10/27/ NC Drug Task Force Recommendations 7.CLINICAL INTERVENTIONS - Recommendations to expand forgery notification systems, improve emergency provider preparedness, increase resources for recovering addicts, and broaden the evidence base for implementing new, effective out-patient and in-patient treatment programs.

NC DHHS Injury and Violence Prevention Branch, 10/27/ NC-DOJ/DHHS Leadership Committee on Drug Overdoses Recommendations premised on a state infra-structure to focus on implementing recommendations. MOU required between NC-DOJ and DHHS, and signed August Committee convened October 2004; meets quarterly. Representation from Law Enforcement; Mental Health, Public Health, Clinical Practice, Pharmacy Practice with IVPB facilitator. Focus for 2005: surveillance and enabling legislation for a controlled substance reporting system

NC DHHS Injury and Violence Prevention Branch, 10/27/ Year 1 Leadership Committee Priorities: Surveillance and PMP Legislation Injury surveillance from death certificates and hospital discharge data on drug-related events; on-going. New data available from Poison Control Center and Emergency Department databases. Enabling legislation required for monitoring prescriptions of controlled substances.

NC DHHS Injury and Violence Prevention Branch, 10/27/ NC Resident Deaths Due to Poisoning by Manner/Intent: 1997 – 2004 SURVEILLANCE

NC DHHS Injury and Violence Prevention Branch, 10/27/ Naming the PMP A controlled substance reporting (CSR) System is a system into which prescription data for designated schedules of controlled substances are reported by dispensers to a central location where the information is entered into an electronic database. North Carolina would report Schedules II-V prescriptions dispensed on an out-patient basis. LEGISLATION

NC DHHS Injury and Violence Prevention Branch, 10/27/ Being Politically Savvy Established leadership authority. Reviewed the history of past failures. Identified stakeholders. Identified credible spokespersons. Identified the opposition. Identified House and Senate sponsors. LEGISLATION

NC DHHS Injury and Violence Prevention Branch, 10/27/ What did we do differently? Re-cast the CSR System as a public health initiative, but … Agreed to have legislation submitted as a revision of the Controlled Substances Law. Worked through the NC-DHHS legislative liaison and legal counsel in DPH. Included legislation as a special amendment to the state budget. LEGISLATION

NC DHHS Injury and Violence Prevention Branch, 10/27/ Next Steps Have legislative rules adopted from the Mental Health Commission. Apply for implementation funding from national sources. Establish a CSR System Advisory Board. Design the actual database. Continue the collaboration between DMH, DPH and DOJ in North Carolina.