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

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

3. 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

4. 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

5. Historical Trend

6. 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

7. OD vs Other Causes

8. Unintentional Drug Overdose Deaths in U.S. during 1999-2007

9. Opioid Production and Consequences

11. 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

12. Crude rates for drug overdose deaths and drug misuse-or abuse-related emergency department visit among women by select drug class

13. 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.

14. 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%

15. ACOME Drug Deaths as % of Morgue and Accidental Cases

16. ACOME Drug Deaths by Age Group

19. Drug Death per Age Group

20. ACOME Drug Deaths by Race/Sex

22. Drug Death by Race/Sex in 2013

23. 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

24. 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 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 Census By William O. Hare and Mark Mather October 2003 Annie E. Casey Foundation, Population Reference Bureau

25. 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

26. Community Need Index – Full County

27. Comparison NEW METHOD Communities Outside the City (Top 50% with Highest Level of Need) OLD METHOD Population Below Federal Poverty Line, 2005-2009 Zoom

28. Comparison OLD METHOD Population Below Federal Poverty Line, 2005-2009 NEW METHOD Communities Outside the City (Top 50% with Highest Level of Need)

29. Overdose by Location - 1

30. Overdose by Home (Residence) Address Overdose by Location - 2

31. Top Ten Tracts by Residence Rate (2002 - 2012) NameTractsIncidentsPopulationRate Chalfant BoroughCensus Tract 5639980011.3 Hays Census Tract 562921192610.9 McDonald BoroughCensus Tract 5640438310.4 Lower Lawrenceville Census Tract 6032023418.5 Bloomfield Census Tract 9031316298.0 Polish Hill Census Tract 6051012747.8 Dormont BoroughCensus Tract 47211925247.5 Mount Washington Census Tract 19151520477.3 Clairton CityCensus Tract 49271318826.9 Allentown Census Tract 18031725006.8

32. Top Ten Tracts by Inciden ts (2002 - 2012) NameTractsIncidents Terrace Village Census Tract 402*88 Bluff Census Tract 103*46 Monroeville MunicipalityCensus Tract 5214.01*28 Shadyside Census Tract 70928 McKeesport CityCensus Tract 551927 Kennedy TownshipCensus Tract 4600.0226 Central Business District Census Tract 20125 O'Hara TownshipCensus Tract 424024 Beechview Census Tract 191623 Brookline Census Tract 191822 *Hospital addresses are commonly given as incident addresses – the majority of the above counts reflect treatment locations not residence location of the individuals.

33. Top Ten Tracts by Residence Rate (2002 - 2012) NameTractsIncidentsPopulationRate Chalfant BoroughCensus Tract 5639980011.3 Hays Census Tract 562921192610.9 McDonald BoroughCensus Tract 5640438310.4 Lower Lawrenceville Census Tract 6032023418.5 Bloomfield Census Tract 9031316298.0 Polish Hill Census Tract 6051012747.8 Dormont BoroughCensus Tract 47211925247.5 Mount Washington Census Tract 19151520477.3 Clairton CityCensus Tract 49271318826.9 Allentown Census Tract 18031725006.8

34. 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%).

35. ACOME Drug Deaths Total Single or Combined

36. 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

37. 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%)

38. ACOME Accidental Overdose Cases

39. Top Eight Drugs Found in Overdose Deaths

40. 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

41. Heroin & Fentanyl

42. Heroin/Fentanyl Cases

43. 2014 Heroin/Fentanyl Crisis

44. Heroin: bricks, bundles, stamp bags…

45. 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.

46. 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