PERMEATING BORDERS OVERDOSE PREVENTION Summer Conference 2014 July 24, 2014 ACOPC Allegheny County Overdose Prevention Coalition Presents

The Overdose Problem in Allegheny County Karl Williams MD, MPH Chief Medical Examiner Allegheny County

The Overdose Problem in Allegheny County 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

Opioid Production and Consequences

Overdoses of Prescription Opioid Pain Relievers and Other Drugs Among Women–U.S., 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 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 ( ) 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, On average, there were 259 cases reported each year during this time period.

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

ACOME Drug Deaths by Age Group

Drug Death per Age Group

ACOME Drug Deaths by Race/Sex

Drug Death by Race/Sex in 2013

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  Percentage of youth ages 16 to 19 without a high school diploma or equivalent, and not enrolled in school  Percentage of civilian males ages 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 Census By William O. Hare and Mark Mather October 2003 Annie E. Casey Foundation, Population Reference Bureau

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 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

Comparison NEW METHOD Communities Outside the City (Top 50% with Highest Level of Need) OLD METHOD Population Below Federal Poverty Line, Zoom

Comparison OLD METHOD Population Below Federal Poverty Line, 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 ( ) NameTractsIncidentsPopulationRate Chalfant BoroughCensus Tract Hays Census Tract McDonald BoroughCensus Tract Lower Lawrenceville Census Tract Bloomfield Census Tract Polish Hill Census Tract Dormont BoroughCensus Tract Mount Washington Census Tract Clairton CityCensus Tract Allentown Census Tract

Top Ten Tracts by Inciden ts ( ) NameTractsIncidents Terrace Village Census Tract 402*88 Bluff Census Tract 103*46 Monroeville MunicipalityCensus Tract *28 Shadyside Census Tract McKeesport CityCensus Tract Kennedy TownshipCensus Tract Central Business District Census Tract O'Hara TownshipCensus Tract Beechview Census Tract Brookline Census Tract *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 ( ) NameTractsIncidentsPopulationRate Chalfant BoroughCensus Tract Hays Census Tract McDonald BoroughCensus Tract Lower Lawrenceville Census Tract Bloomfield Census Tract Polish Hill Census Tract Dormont BoroughCensus Tract Mount Washington Census Tract Clairton CityCensus Tract Allentown Census Tract

Other Observations ( ) 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

ACOME Drug Deaths Most drug deaths involve multiple drugs (61%> 1 drug) Single drug deaths in attributed to cocaine, heroin or alcohol Alcohol listed on death certificate on 18-24% of drug deaths in 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

Top Eight Drugs Found in Overdose Deaths

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 ( 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

2014 Heroin/Fentanyl Crisis

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 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