prescription drug overdose in north carolina state health director’s meeting jan 24 th, 2014
TRANSCRIPT
Prescription Drug OverdoseIn North Carolina
State Health Director’s MeetingJan 24th, 2014
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
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
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
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
Problem Overview:US Prescription Overdose
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
November 2011
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
North Carolina Poisonings Data
11
Unintentional Poisoning and Motor Vehicle DeathsNorth Carolina Residents, 1999–2012
National Vital Statistics System, http://wonder.cdc.gov, multiple cause dataset
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200
400
600
800
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1200
1400
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1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012Source: Death files 1999-2012, State Center for Health Statistics. Analysis by Injury Epidemiology and Surveillance Unit
Motor Vehicle/Transportation
Poisoning
Unintentional Poisoning Deaths by Drug Type and Year: N.C. Residents, 1999-2012
Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 1999-2012 (2012 Provisional)Analysis by Injury Epidemiology and Surveillance Unit
Note: categories are not mutually exclusive
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1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Opioid Pain Medications
Cocaine
Heroin
Unintentional Poisoning Deaths, 1999-2001
Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 1999-2012Analysis by Injury Epidemiology and Surveillance Unit
Unintentional Poisoning Deaths, 2002-2005
Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 1999-2012Analysis by Injury Epidemiology and Surveillance Unit
Unintentional Poisoning Deaths, 2006-2009
Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 1999-2012Analysis by Injury Epidemiology and Surveillance Unit
Unintentional Poisoning Deaths, 2010-2012
Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 1999-2012Analysis by Injury Epidemiology and Surveillance Unit
Personal Stories: The Polarizing Effect of Drug Abuse
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
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: http://www.harryecohen.com/
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
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”
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
North Carolina’s Response:Coordinating between Partners
North Carolina Injury and Violence Prevention BranchEpidemiology, Policy, Partners, Community
Poisoning Death StudyComprehensive Community Approach
Chronic Pain InitiativeOpioid Death Task Force
Policy & Practice Research
North Carolina
Policy
Monitoring System
Drug Take Back
Prescription Drug
Substance Abuse
Div. of Public Health
SAC Poisoning Workgroup
Enforcement
SBI & Medical Board
Div. Medical AssistanceDiv. Mental Health/Substance Abuse
North Carolina’s Response:Take Back Events
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
Safe Kids and Operation Medicine Drop facilitate safe disposal of medicines in NC
Searchable index of community drop-off locations & community take-back events
North Carolina’s Response:Realtime ED Surveillance of Drug
Overdose in Your County
Deaths vs. ED visits for drug overdose, NC 2011
The number of ED visits for overdose dwarfs the number of overdose deaths
22,992 ED visits
1,222 deaths
© 2014 University of North Carolina at Chapel Hill and NC Division of Public Health, NC DHHS
Average NC county has about one overdose death per month but just under one overdose ED visit per day
Unintentional Poisoning ED Visits, 2011
Source: Division of Public Health, NC DETECT-ED visit data, 2011Analysis by Injury Epidemiology and Surveillance UnitNC DETECT coding for substance abuse, Dx and E-codes as primary
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.
© 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
© 2014 University of North Carolina at Chapel Hill and NC Division of Public Health, NC DHHS
© 2014 University of North Carolina at Chapel Hill and NC Division of Public Health, NC DHHS
Dashboard of Overdose Reports For Your County
Opioid OD Graph from NC DETECT
© 2014 University of North Carolina at Chapel Hill and NC Division of Public Health, NC DHHS
© 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 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.
XX XX DRUG OVERDOSE
denies suicide, crushed and injected XXX
XX XXDRUG OVERDOSE
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 ….
XX XX 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
© 2014 University of North Carolina at Chapel Hill and NC Division of Public Health, NC DHHS
Account Request
© 2014 University of North Carolina at Chapel Hill and NC Division of Public Health, NC DHHS
http://www.ncdetect.org/
NC DETECT Training• Contact Jenna Waggoner or Amy Ising for
customized Web-based or in-person training – [email protected]– [email protected] (919) 966-8853
• NC DETECT User Guide available online• Help icon on dashboard reports
© 2014 University of North Carolina at Chapel Hill and NC Division of Public Health, NC DHHS
NC Controlled Substance Reporting System (CSRS)
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
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.
UNC IPRCOverdose Research
UNC IPRC Research• Funding:
– 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
• 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
Acknowledgements
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
Thank you!