Recommendations for Fatal Drug Overdose Surveillance

Methodology and Data Quality Improvements:

A Follow-up to the Safes States Injury Surveillance

Workgroup on Poisoning

CSTE Overdose

Subcommittee Presentation

2016 Annual Meeting

Safe States Alliance

April 12-14, Albuquerque, NM

Presenters and Co-Authors

• Dr. Svetla Slavova, PhD, Kentucky Injury Prevention and Research Center

• James W Davis, MA, New Mexico Department of Health

• Dr. Denise Paone, EdD, New York City Department of Health and Mental Hygiene

• Barbara Gabella, MSPH, Colorado Department of Public Health and Environment

Co-Authors:

• Dr. Jennifer C Sabel, PhD, Washington State Department of Health

• Dr. Dagan A Wright, PhD, MSPH, Oregon Health Authority – Department of

Public Health

Fatal Drug Overdose Surveillance

“Levels 1 - 4”

Level 4: Toxicology and

Literals

Level 3: Literal text from death certificate

Level 2: Multiple Cause

Level 1: Basic Underlying

cause of death file

Agenda

• Safe States & CSTE (Denise)

• Levels 1 and 2 (Svetla)

• Level 3 & Epi tool for everyone (Jim)

• Level 4 (Denise)

• Lessons learned paper (Svetla, Denise, Jim)

• Future & your ideas (Barbara)

Safe States Background

• Safe States Poisoning

Workgroup – 2008

• Safe States forms Injury

Surveillance Workgroup (ISW7)

• ISW7 Publication – 2012

• Conferences of CDC, Safe

States, CSTE - 2012

CSTE Background

• Council of State and Territorial Epidemiologists (CSTE)

• CSTE Drug Overdose

– Willing and wanting to test ISW7 indicators

– Providing organizational base for effort

• Real partnership with Safe States – liaison

• Scott Proescholdbell

www.cste.orgUsing the power of epidemiology to improve

the public’s health

Why CSTE Overdose Subcommittee

chose this work

• Increased attention and need to track drug overdose

• Lack of consistent definitions and indicators

• Variations across states and local jurisdictions

• Recognition that lack of detail on death certificates

underestimates deaths for specific drugs

• Concern about shifting from opioid analgesics to heroin

→ accurate classification of opiates critical

Timeline 2012-2013

• August 2012 - Organizational call

• Creation of Poisoning Surveillance Workgroup

• Fall 2012 - Creation of tables shells and Levels I-IV (basic

to complex)

• Winter- submission of data by volunteer states and

proposal to present data

• Spring 2013 - Data results & write up of methods and

process for Special Emphasis Report

• April 2013 - CDC meeting on poisoning for Core states

Fatal Drug Overdose Surveillance

“Levels 1 - 4”

Level 4: Toxicology and

Literals

Level 3: Literal text from death certificate

Level 2: Multiple Cause

Level 1: Basic Underlying

cause of death file

Svetla Slavova, PhD

Associate Professor, University of Kentucky

Kentucky Injury Prevention and Research Center

Underlying and Multiple

Causes of Death

(Level 1 and 2)

Level 1 Background

• Underlying cause of death and multiple causes of death listed on death certificates are coded in ICD-10.

• A drug overdose death is defined as a death with an underlying cause of death in these ICD-10 ranges:– X40–X44 (unintentional),

– X60–X64 (suicide),

– X85 (assault), and

– Y10–Y14 (undetermined intent).

• ICD-10 codes T36 -T50 identify the specific drugs or drug classes contributing to an overdose deaths.

• The next three slides are examples of how the information might appear on the death certificate and in the electronic data file.

CAUSE OF DEATH (See instructions and examples) Approximate

interval:

Onset to death32. PART I. Enter the chain of events - - diseases, injuries, or complications - - that directly caused the death. DO NOT enter

terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT

ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.

IMMEDIATE CAUSE (Final

disease or condition resulting in death)a. ANOXIA BRAIN INJURY

Sequentially list conditions,

if any, leading to the cause

listed on line a. Enter the

UNDERLYING CAUSE (disease

or injury that initiated the events

resulting in death) LAST

Due to (or as a consequence of):

b. SECONDARY TO INGESTION OF METHADONE

Due to (or as a consequence of):

c.

Due to (or as a consequence of):

d.

PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause

given in Part I.

33. WAS AN AUTOPSY PERFORMED?

Yes No

34. WERE AUTOPSY FINDINGS AVAILABLE

TO COMPLETE THE CAUSE OF DEATH?

Yes No

35. DID TOBACCO USE

CONTRIBUTE TO DEATH?

Yes Probably

No Unknown

36. IF FEMALE:

Not pregnant within past year

Pregnant at time of death

Not pregnant but pregnant within 42 days of death

Not pregnant but pregnant 43 days to 1 year before death

Unknown if pregnant within the past year

29. MANNER OF DEATH

Natural Pending

Accident Investigation

Suicide Could not be

Homicide Determined

38. DATE OF INJURY

(Mo/Day/Yr)(Spell Month)

39. TIME OF INJURY 40. PLACE OF INJURY (e.g., Decedent’s home, construction

site, restaurant, wooded area)

HOME

41. INJURY AT WORK?

Yes No

42. LOCATION OF INJURY: State: City or Town:

Street & Number: Apartment No. Zip Code:

43. DESCRIBE HOW INJURY OCCURRED

DRUG INGESTION

44. IF TRANSPORTATION INJURY, SPECIFY

Driver/Operator

Passenger

Pedestrian

Other (Specify)

To B

e C

om

ple

ted B

y:

ME

DIC

AL C

ER

TIF

IER

X

CAUSE OF DEATH (See instructions and examples) Approximate

interval:

Onset to death32. PART I. Enter the chain of events - - diseases, injuries, or complications - - that directly caused the death. DO NOT enter

terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT

ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.

IMMEDIATE CAUSE (Final

disease or condition resulting in death)a. ANOXIA BRAIN INJURY

Sequentially list conditions,

if any, leading to the cause

listed on line a. Enter the

UNDERLYING CAUSE (disease

or injury that initiated the events

resulting in death) LAST

Due to (or as a consequence of):

b. SECONDARY TO INGESTION OF METHADONE

Due to (or as a consequence of):

c.

Due to (or as a consequence of):

d.

PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause

given in Part I.

33. WAS AN AUTOPSY PERFORMED?

Yes No

34. WERE AUTOPSY FINDINGS AVAILABLE

TO COMPLETE THE CAUSE OF DEATH?

Yes No

35. DID TOBACCO USE

CONTRIBUTE TO DEATH?

Yes Probably

No Unknown

36. IF FEMALE:

Not pregnant within past year

Pregnant at time of death

Not pregnant but pregnant within 42 days of death

Not pregnant but pregnant 43 days to 1 year before death

Unknown if pregnant within the past year

29. MANNER OF DEATH

Natural Pending

Accident Investigation

Suicide Could not be

Homicide Determined

38. DATE OF INJURY

(Mo/Day/Yr)(Spell Month)

39. TIME OF INJURY 40. PLACE OF INJURY (e.g., Decedent’s home, construction

site, restaurant, wooded area)

HOME

41. INJURY AT WORK?

Yes No

42. LOCATION OF INJURY: State: City or Town:

Street & Number: Apartment No. Zip Code:

43. DESCRIBE HOW INJURY OCCURRED

DRUG INGESTION

44. IF TRANSPORTATION INJURY, SPECIFY

Driver/Operator

Passenger

Pedestrian

Other (Specify)

To B

e C

om

ple

ted B

y:

ME

DIC

AL C

ER

TIF

IER

X

G93.1 Anoxic brain damage, NEC

T40.3 Methadone

T50.9 Other and unspecified drug

X42 Accidental poisoning and exposure to

narcotics and psychodysleptics, NEC

Part I Part II Underlying Cause Multiple Causes of Death

How injury occurred Manner Line a Line b Line c Line d

Significantconditions

contributing to death

ICD-10 Code Text

1st in ICD-10 1 in Text

2nd in ICD-10 2nd in Text

3rd in ICD-10 3rd in Text

PRESCRIPTION DRUG OVERDOSE ACCIDENT ANOXIC BRAIN INJURY

ACUTE OXYCODONE TOXICITY X42

Accidental poisoning by and exposure to narcotics and psychodysleptics [hallucinogens], NEC G931

Anoxic brain damage, not elsewhere classified T402

Poisoning, other opioids T509

Poisoning, Other and unspecified drugs

INJECTED HEROIN ACCIDENT HEROIN INTOXICATION X42

Accidental poisoning by narcotics and psychodysleptics [hallucinogens], NEC F119

Unspecified mental and behavioral disorder T401

Poisoning, heroin

MULTIPLE DRUG INTOXICATION ACCIDENT

MULTIPLE DRUG INTOXICATION (OXYCODONE AND DIAZEPAM) X44

Accidental poisoning by and exposure to other and unspecified drugs T402

Poisoning, other opioids T424

Poisoning, Benzodiazepines T509

Poisoning, Other and unspecified drugs

USED TOXIC LEVEL OF BATH SALTS ACCIDENT

ACUTE ALPHA-PVP TOXICITY (BATH SALTS)

HISTORY OF DRUG ABUSE X44

Accidental poisoning by and exposure to other and unspecified drugs T509

Poisoning, Other and unspecified drugs F191 Harmful use

COMBINED DRUG TOXICITY ACCIDENT

COMBINED DRUG TOXICITY X44

Accidental poisoning by and exposure to other and unspecified drugs T509

Poisoning, Other and unspecified drugs

SUBJECT WAS FOUND UNRESPONSIVE IN BED BY A FAMILY SUICIDE

ACUTE COMBINED DRUG TOXICITY (LORAZEPAM, BUPROPION, VENLAFAXINE) X61

Intentional self-poisoning (suicide) by and exposure to antiepileptic, sedative-hypnotic, antiparkinsonism, and psychotropic drugs,NEC T424

Poisoning, Benzodiazepines T432

Poisoning, other and unspecified antidepressants T509

Poisoning, Other and unspecified drugs

DECEDENT INGESTED DRUGS

UNDETERMINED

ACUTE FENTANYL INTOXICATION Y12

Poisoning by and exposure to narcotics and psychodysleptics[hallucinogens], not elsewhere classified, undetermined intent T404

Poisoning, other synthetic narcotics T509

Poisoning, Other and unspecified drugs

Level 1 Example Text & Codes

Used “underlying cause of death” only

Classification by intent and by drug type

11 states (KS, KY, MA, MD, MI, NC, NYC, OK, OR, UT, WA)

produced the Safe States ISW7 recommended indicators

Drug Type Unintentional Suicide Undetermined Homicide

Nonopioid analgesics,

antipyretics and anti-

rheumatics

X40 X60 Y10

X85

Sedative-hypnotic,

psychotropic

X41 X61 Y11

Narcotics and

psychodysleptics

(hallucinogens), NOS

X42 X62 Y12

Other drugs acting on

CNS

X43 X63 Y13

Other and unspecified

drugs

X44 X64 Y14

Level 1 Method

Level 1 Results(Underlying Cause of Death only)

Comparing states/jurisdictions on drug overdose rates by

intent could be misleading!

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

Percentage of Drug Overdose Deaths with "Undetermined" Intent, By State, 2014

Level 1 Results

Level 1 Results

CSTE Overdose Subcommittee

Recommendations

• It is better to report all drug overdoses, regardless of

intent, for state-to-state comparisons.

• Categorization by intent is still useful, for example, to

examine the proportion of the drug overdose deaths

by intent over time within a given state/jurisdiction.

Fatal Drug Overdose Surveillance

“Levels 1 - 4”

Level 4: Toxicology and

Literals

Level 3: Literal text from death certificate

Level 2: Multiple Cause

Level 1: Basic Underlying

cause of death file

Level 2 Method

• Use underlying cause of death and multiple causes of death to identify drugs contributing to overdose deaths.

• When no specific drugs/classes of drugs are listed on the death certificate, the overdose is attributed to– “Other and Unspecified Drugs”, coded with ICD-10 code T50.9.

• An overdose death could be attributed to “Other and Unspecified Drugs” when – it involves drug that cannot be classified under any other existing

category (e.g., “bath salts”).

7,577

8,297

0 2000 4000 6000 8000 10000

Y14 (Poisoning by and exposure to other and unspecified drugs,medicaments and biological substances, undetermined intent)

Y12 (Poisoning by and exposure to narcotics and psychodysleptics[hallucinogens], not elsewhere classified, undetermined intent)

X85 (Assault by drugs, medicaments and biological substances)

X64 (Intentional self-poisoning by and exposure to other andunspecified drugs, medicaments and biological substances)

X62 (Intentional self-poisoning by and exposure to narcotics andpsychodysleptics [hallucinogens], not elsewhere classified)

X44 (Accidental poisoning by and exposure to other and unspecifieddrugs, medicaments and biological substances)

X42 (Accidental poisoning by and exposure to narcotics andpsychodysleptics [hallucinogens], not elsewhere classified)

U.S. Drug Overdose Deaths by Selected Underlying and Multiple Causes of Death, 2014

Cocaine (T40.5) Heroin (T40.1) Pharmaceutical opioids (T40.2, T40.3, or T40.4)

Level 2 Example Text & Codesfor underlying cause of death and multiple causes of death

Part I Part II Underlying Cause Multiple Causes of Death

How injury occurred Manner Line a Line b Line c Line d

Significantconditions

contributing to death

ICD-10 Code Text

1st in ICD-10 1 in Text

2nd in ICD-10 2nd in Text

3rd in ICD-10 3rd in Text

PRESCRIPTION DRUG OVERDOSE ACCIDENT ANOXIC BRAIN INJURY

SECONDARY TO INGESTION OF METHADONE X42

Accidental poisoning by and exposure to narcotics and psychodysleptics [hallucinogens], NEC G93.1

Anoxic brain damage, not elsewhere classified T40.3

Poisoning, methadone T50.9

Poisoning, Other and unspecified drugs

INJECTED HEROIN ACCIDENT HEROIN INTOXICATION X42

Accidental poisoning by narcotics and psychodysleptics [hallucinogens], NEC F11.9

Unspecified mental and behavioral disorder T40.1

Poisoning, heroin

MULTIPLE DRUG INTOXICATION ACCIDENT

MULTIPLE DRUG INTOXICATION (OXYCODONE AND DIAZEPAM) X44

Accidental poisoning by and exposure to other and unspecified drugs T40.2

Poisoning, other opioids T42.4

Poisoning, Benzodiazepines T50.9

Poisoning, Other and unspecified drugs

USED TOXIC LEVEL OF BATH SALTS ACCIDENT

ACUTE ALPHA-PVP TOXICITY (BATH SALTS)

HISTORY OF DRUG ABUSE X44

Accidental poisoning by and exposure to other and unspecified drugs T50.9

Poisoning, Other and unspecified drugs F19.1 Harmful use

COMBINED DRUG TOXICITY ACCIDENT

COMBINED DRUG TOXICITY X44

Accidental poisoning by and exposure to other and unspecified drugs T50.9

Poisoning, Other and unspecified drugs

SUBJECT WAS FOUND UNRESPONSIVE IN BED BY A FAMILY SUICIDE DRUG OVERDOSE X61

Intentional self-poisoning (suicide) by and exposure to antiepileptic, sedative-hypnotic, antiparkinsonism, and psychotropic drugs,NEC T50.9

Poisoning, Other and unspecified drugs

Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple Cause of Death 1999-2014 on CDC WONDER Online Database, released 2015.

Data are from the Multiple Cause of Death Files, 1999-2014, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative

Program. Accessed at http://wonder.cdc.gov/mcd-icd10.html on Mar 30, 2016 1:51:15 PM

Level 2 Results

Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple Cause of Death 1999-2014 on CDC WONDER Online Database, released 2015.

Data are from the Multiple Cause of Death Files, 1999-2014, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative

Program. Accessed at http://wonder.cdc.gov/mcd-icd10.html on Mar 30, 2016 1:51:15 PM

Level 2 Results

Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple Cause of Death 1999-2014 on CDC WONDER Online Database,

released 2015. Data are from the Multiple Cause of Death Files, 1999-2014, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital

Statistics Cooperative Program. Accessed at http://wonder.cdc.gov/mcd-icd10.html on Mar 30, 2016 1:51:15 PM

Drug Overdose Deaths: Let’s Get Specific.

Slavova, S., Bradley O’Brien, D., Creppage, K., Dao, D., Fondario, A., Haile, E., Hume, B., Largo, T., Nguen, C.,

Sabel, J., Wright, D.

Public Health Reports.

July-August 2015. Volume 130, pg.339-342

CSTE Overdose Subcommittee

Recommendations

• The use of nonspecific language to identify specific drugs

on death certificates can result in undercounting various

drug classes.

• Ranking jurisdictions by specific drug types identified on

death certificates might be misleading and should be

accompanied by analysis of the level of completeness and

specificity of the jurisdictional data.

CSTE Overdose Subcommittee

Recommendations

Epidemiologists and other public health practitioners:

• Need to be aware of the quality and limitations of the death

certificate data in their jurisdiction,

• Evaluate when possible the level of completeness and

accuracy of their Multiple Cause of Death data, and

• Interpret the reported counts and rates with caution when

the proportion of deaths with ‘Other and Unspecified Drugs”

is considerable.

CSTE Overdose Subcommittee

Recommendations

At the state and local jurisdictions, where possible:

• Identify and address factors that contribute to differences in

how states record drug overdose deaths.

• Compare with medical examiner/coroner and state

toxicology laboratory records, exactly which drugs were

involved in deaths coded nonspecifically to provide better

estimates of the contributions of individual drug types to

their overdose problem.

Fatal Drug Overdose Surveillance

“Levels 1 - 4”

Level 4: Toxicology and

Literals

Level 3: Literal text from death certificate

Level 2: Multiple Cause

Level 1: Basic Underlying

cause of death file

Literal Text Fields

and

Beyond ICD-10

(Level 3)

Jim Davis

Drug Epidemiologist

New Mexico Department of Health

Level 3 Background

• In overdose deaths, text literals often contain:• Toxic effects of heroin [or oxycodone, or methamphetamine, …]

• Multiple drug (heroin, methadone and alcohol) intoxication

• Atherosclerotic cardiovascular disease and methamphetamine toxicity

• ICD-10 coding collapses some categories of interest

• Particularly the prescription opioids and benzodiazepines

• Text recognition not a new thing, but no general tool existed

for drug recognition in death data

Level 3 Methods & Epi Tool

• SAS program adapted from NM work

– Uses macro variables to define the variable names

– Can scan one or more of:• 4 variables for cause of death text

• 1 variable for “other factors” (part II)

• 1 variable for injury description

• Simple word-by-word search of specified literal text variables

• Common drugs found on death certificates listed by NCHS

– Includes generic and trade names

– Includes common abbreviations and misspellings

Example of Drug List

Terms found on

death certificates Drug

Misspelling

or Metabolite

Substance

Type

Pharmacologic

Type

ICD T Code Drug

Classification

DARVOCET PROPOXYPHENE Brand opioid

T40.2-T40.4 (opioid

analgesics)

DARVON PROPOXYPHENE Brand opioid

T40.2-T40.4 (opioid

analgesics)

DEXTROPROPOX

YPHENE PROPOXYPHENE Metabolite

Unspecified

brand or

generic opioid

T40.2-T40.4 (opioid

analgesics)

PROOXYPHENE PROPOXYPHENE Misspelling Generic opioid

T40.2-T40.4 (opioid

analgesics)

PROPOSYPHENE PROPOXYPHENE Misspelling Generic opioid

T40.2-T40.4 (opioid

analgesics)

PROPOXIPHENE PROPOXYPHENE Misspelling Generic opioid

T40.2-T40.4 (opioid

analgesics)

Level 3 Methods (continued)

• Generates a list (array) of drug names and classifications

• Plus a slash-separated list of drug names (e.g.

OXYCODONE/ALPRAZOLAM)

• Additional programming is needed to create variables for

analysis or reporting

• Available on the CSTE web site (in SAS) :

http://www.cste.org/members/group.aspx?id=87615

• R version also available (Chris Ryan – Binghamton, NY)

• Has been used in several states (NM, KY, OR, . . .)

Limitations

• Assumes knowledge of SAS (or R)

• Specificity issues/completeness of the input data– “Mixed drug intoxication” is not specific

– Specificity varies by jurisdiction and over time

• Consistency over time – Different jurisdictions code differently

– Approaches to coding change over time

• Limitations of the list– Infinite number of ways to misspell drug names

• Does not try to resolve morphine vs. heroin– Morphine is the primary metabolite of heroin

An Example from NM Data

0

2

4

6

8

10

12

14

19

90

19

91

19

92

19

93

19

94

19

95

19

96

19

97

19

98

19

99

20

00

20

01

20

02

20

03

20

04

20

05

20

06

20

07

20

08

20

09

20

10

20

11

20

12

20

13

20

14

Death

s p

er

100,0

00

po

pu

lati

on

Drug Overdose Death rates for Selected Drugs, NM 1990-2014

Rx Opioid Heroin Methamphetamine Cocaine

Drug categories are not mutually exclusive2014 rates preliminaryRates age-adjusted to the US 2000 standard populationSource: Office of the Medical Investigator; UNM/GPS population

Top Rx Drugs in Overdose Death, NM 2014

0 20 40 60 80 100 120

oxycodone

hydrocodone

alprazolam

morphine

methadone

fentanyl

diazepam

Overdose death involvements

Deaths may involve more than one drugSource: NM Office of the Medical Investigator

An Example from Kentucky Data

0

50

100

150

200

250

300

2011 2012 2013 2014

Invo

lvem

en

ts

Selected Drugs Commonly Listed as Contributing to Kentucky Resident Drug Overdose Deaths, 2011-2014

Alprazolam Oxycodone Hydrodocone Fentanyl Heroin

2011-2014 data are provisional and subject to changeSource: http://www.mc.uky.edu/kiprc/programs/KVIPP/drug_overdose_deaths_00-14.pdf – Table 2Fentanyl increase in 2014 primarily due to illicit fentanyl

Level 3 Wrap up

• Literal text in death data can be useful for a variety of problems.

• Used experimentally with other data sources (ED, EMS)

• Epi tool available from CSTE website for SAS:

http://www.cste.org/members/group.aspx?id=87615

• Further development is possible to suit various needs.

Fatal Drug Overdose Surveillance “Levels 1 - 4”

Level 4: Toxicology and

Literals

Level 3: Literal text from death certificate

Level 2: Multiple Cause

Level 1: Basic Underlying

cause of death file

Multistage Analysis

(Introduction to Level 4)

Denise Paone, EdD

Senior Director of Research and Surveillance

New York City Department of Health and Mental Hygiene

Bureau of Alcohol and Drug Use Prevention, Care, and

Treatment

Issues

• 23% of drug overdose deaths in 2012, there were

not any drugs listed on the death certificate (wide

range).

• Morphine is used on death certificates. Does this

mean heroin or pharmaceutical morphine?

• Medical examiners have toxicology data that could

help improve accuracy.

• Death certificate (literals)

• Toxicology results

• Electronic records

• Chart review• Requires capacity

• Coroner/Medical examiner office

• Confirm they test for drug metabolites

• Familiarity with the drug metabolites

What do you need for Level 4?

Level 4 Approach

Compare toxicology results to drugs listed on the death

certificates and corresponding T codes across three

jurisdictions participating in CSTE Overdose

Subcommittee

Level 4 Objectives

• Determine the sensitivity of death certificates for

identifying drug-specific poisoning deaths in three

jurisdictions (NYC, OR, King County WA)

• Is there variation by jurisdiction?

• Next steps - How to improve sensitivity

Level 4 Methods

• Limited to unintentional drug poisoning (overdose) deaths

– Using death certificate (underlying, contributing)

• Limited to decedents 15-84 years old

• Linked death certificates to toxicology files for 2012

Level 4 Methods

• Included: benzodiazepines, cocaine, heroin, methadone,

other opioid analgesics, and methamphetamines

• All metabolites were included.

• NYC did not report methamphetamine.

Level 4 Methods

• For toxicology reports indicating morphine, relied on literal

text

– Pharmaceutical morphine = opioid analgesic

– Probable pharmaceutical morphine = opioid analgesic

– All other morphine = heroin

– Morphine + codeine = heroin

– Includes cases where the source of the morphine was

listed as unknown on death certificate

T-Codes

Drug Category ICD-10 code

Benzodiazepines T42.4

Cocaine T40.5

Heroin T40.1

Methadone T40.3

Methamphetamine (Psychostimulants) T43.6

Other opioid analgesics

Natural and semi-synthetic opioid analgesics

(aka “Other opioids”)T40.2

Synthetic opioid analgesics, excluding

methadone (aka “other synthetic narcotics”)T40.4

Sensitivity

• Calculated the sensitivity of the death certificate to detect drug-specific poisoning deaths, using the toxicology results as the gold-standard:

• The sensitivity of death certificates were calculated separately for benzodiazepines, cocaine, heroin, methadone, and opioid analgesic-involved deaths.

Sensitivity =Ʃ Condition positive (Death certificate)

Ʃ True positive (Toxicology)

Comparing toxicology results and

death certificate

Drug Type # of Deaths w/ Drug

Present in Toxicology

Results

# of Deaths w/

Appropriate T

Code

Sensitivity

Benzodiazepine 431 262 60.8%

Cocaine 412 302 73.3%

Heroin 594 414 69.7%

Methadone 289 250 86.5%

Methamphetamine** 83 77 92.8%

Other Opioid

Analgesics 308 295 95.8%

** Methamphetamine compared in OR & King County, WA only.

Sensitivity of death certificate compared

to toxicology by jurisdiction

88%

95%92%

100%97%

100%

68%71%

61%

82%

91%

23%

71%

82%

91% 90%

107%

0%

20%

40%

60%

80%

100%

120%

Benzodiazepine Cocaine Heroin Methadone Methamphetamine Other OpioidAnalgesics

Perc

en

tag

e

WA (King County) NYC OR

Number of drug deaths with toxicology

missing from death certificates by jurisdiction

72 6

0 1 0

90

102

150

34

18

72

6

24

5 5 -5

-10

10

30

50

70

90

110

130

150

170

Benzodiazepine Cocaine Heroin Methadone Methamphetamine Other OpioidAnalgesics

Dif

fere

nc

e b

etw

ee

n t

ox

& d

ea

th c

ert

ific

ate

s

WA (King County) NYC OR

Level 4 Summary

• Benzodiazepines had the lowest sensitivity in the

three jurisdictions.

• Heroin sensitivity was second lowest.

• Sensitivity varied most widely for benzodiazepines.

• King County, WA had highest sensitivity of three

jurisdictions across all drug categories (except 107%

in OR – opioid analgesics).

Level 4 Conclusions

• Using death certificates alone results in underreporting

of drug-specific mortality rates.

• Important to note that using death certificates alone will

provide the number of drug poisoning deaths.

• Death certificate sensitivity varies by drug type and

jurisdiction.

Level 4 Conclusions

• Discordance between toxicology findings and literal

on death certificate, thus T-codes.

• Impact of F-codes on reporting drug poisoning

deaths– Why does “Acute and Chronic” not always get X(acute) code?

• Potential misclassification of Opioid Analgesic and

Heroin deaths

• Increasing concern about transitioning to heroin,

critical not to under report

Level 4 Implications

• Underestimation of drug-specific mortality on death

certificates can compromise effective targeting of

resources and public health interventions.

• Medical examiner/coroner information on drug-related

deaths could be systematically included in death certificate

cause-of-death documentation.

• There is no national standard to report drug poisoning

deaths. National standards could provide guidance for

drug-specific reporting and interpretation of toxicology

results.

Lessons Learned

Paper by members of CSTE Overdose

Recommendations & Lessons Learned for Improved

Reporting of Drug Overdose Deaths on Death

Certificates

Jennifer Sabel1, Ellenie Tuazon2, Denise Paone2, Svetla Slavova3,

Terry Bunn3, Dan Dao4, David Nordstrom5, Holly Hedegaard6

Affiliations: 1 Washington State Department of Health2 New York City Department of Health and Mental Hygiene3 Kentucky Injury Prevention and Research Center4 Kansas Department of Health and Environment5 Wisconsin Department of Health6 National Center for Health Statistics

Recommendations for epidemiologists

• Learn more about existing studies, methods and tools – Baseline state-to-state comparison of drug overdose deaths1

– Evaluation of the completeness and accuracy of the multiple cause-of-

death fields for drug overdose deaths2

– CSTE Overdose Subcommittee Epi tool

• Review your drug overdose data– CDC National Center for Injury Prevention and Control’s State Special

Emphasis Report (SER) Instructions for Drug Overdose Death Data

– Assess data quality • % of drug overdose deaths with unspecified drugs (T50.9, T40.6)

• % all deaths (not just drug overdose deaths) with an underlying cause of R99

• Collaborate with state vital statistics registrar • Share observations about the quality of the data from death certificates

on drug overdose deaths with their state vital statistics registrar

1. Warner M, Paulozzi LJ, Nolte KB, Davis GG, Nelson LS. (2013). State Variation in Certifying Manner of Death and Drugs Involved in Drug

Intoxication Deaths. Acad Forensic Pathol, 3(2), 231-237.

2. Slavova S, Bradley O’Brien D, Creppage K, Dao D, Fondario A, Haile E, Hume B, Largo T, Nguen C, Sabel J, Wright D. (2015). Drug

Overdose Deaths: Let’s Get Specific. Public Health Rep, 130, 339-341

Kentucky Experience:Collective effort of multiple stakeholders in the state (Office of the Chief Medical Examiner,

Kentucky Coroner’s Association, Office of Vital Statistics, Office of Drug Control Policy,

Kentucky Injury Prevention and Research Center, legislators, and others).

Source: Drug Overdose Deaths, Hospitalizations, and Emergency Department Visits in Kentucky, 2000-2012. KIPRC. January, 2014.

NYC: Collaborate with local vital

statistics registrar Issues we have discussed with local medical examiners:

1) Deaths coded as “acute and chronic substance use,” which resulted in these deaths being

assigned an underlying cause of death as ‘related to mental health or behavior’, and

coded with an F-code

– Follow-up with OCME on this issue resulted in improved fewer F-codes and an

increase in drug overdose deaths

2) Heroin deaths with coding as “morphine”

– Follow-up with OCME on this issue to consistently include 6-monoacetlylmorphine on

the death certificate as positive toxicology for heroin

– OCME started testing for 6-monoacetlymorphine in urine and vitreous samples to their

standard protocols, resulted in improved specificity of heroin-involved overdose deaths

3) Lack of drug specificity in literals: heroin deaths as “opiate” or “opioid” deaths, use of

“multiple drug toxicity” or “multiple drug involvement”

– Medical examiners acknowledged this issue, and many were committed to improving

this in their work.

– Other issues were also brought up including cocaine-involved and benzodiazepine

involved

Continued collaboration is key

• Reporting on drug overdose surveillance requires

collaboration and communication with medical examiner

• Presentation of aggregate data useful

– Medical examiners look at cases, not aggregate

– Highlights trends

– Describes drug specificity

– Generates discussion

• Check with medical examiners on testing practices

– Fentanyl

New Mexico: Working with

the Medical Investigator

• Central statewide Medical Investigator

• Long relationship with DOH/Epi – providing death data

• Very high level of specific drug coding – in a separate table

• “Multiple drug toxicity” in the text fields, but specifics

available

• Changed their database system in mid 2010, dropping that

table

• New group of pathologists and new leadership

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

*2015 based on January-June

Source: Office of the Medical Investigator, UNM/GPS population estimates

Percent of Drug Overdose Deaths with

Specific Drugs Coded, NM, 1990-2015

NM: Working with

the Medical Investigator

• Annual data transfer, so problem not noticed until

mid 2011

• Initial failure to understand what had happened

• Meeting in early 2012 with agreement to list drugs

in the text fields

• Lessons:

– Pay Attention!

– Maintain relationships – keep in touch

– Ask questions

Barbara Gabella, MSPH

Injury Epidemiologist

Colorado Department of Public Health and

Environment

Future projects?

Future Project?

• Several states test BRFSS questions on chronic pain,

opioid use, or misuse

– Utah presented on their results

– Search and update voluntary database on state

added BRFSS questions

– NM will measure chronic pain

– Recommend question set for multiple states to field?

Future Project?

• Survey states about testing

– Able to distinguish source of the morphine?

• Heroin, fentanyl, and heroin/fentanyl overdose deaths

– Drafting methods

– Similar to studies described today

– Volunteer states analyze deaths in 2015

– Preliminary results for CSTE pre-conference

workshop mid-June

Significance to the Field

• Need: Accurate data to evaluate effectiveness of the laws, policies, and system changes intended to prevent drug overdoses.

• Improved drug overdose surveillance methodology and data quality

• Increased collaboration among epidemiologists Come join us or tell your staff!

• Goal: Increased capacity to address emerging drug overdose surveillance problems.

– Heroin

– Fentanyl-laced heroin

Questions? Ideas?

• CSTE Drug Overdose Subcommittee

meets monthly on the 2nd Thursday

• 1:00pm to 2:00pm Eastern time

• Dial in number: 877-626-7137

• Pass code: 695041#

• Contact: Nidal Kram at nkram@cste.org