the death toll of prescription drug abuse: statistics and analysis, past and present al mock, md,...

The Death Toll of Prescription Drug Abuse:

Statistics and Analysis, Past and Present

Al Mock, MD, MS, DABP, FCAP, FNAMEWV Chief Medical Examiner

October 25, 2014Charleston, WV

Polypharmacy

2

Most Drug Overdose Deaths Involve Multiple Substances

Trend in Deaths

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130

100

200

300

400

500

600

700

212243

286

367

406

475 489521

479

568

656

568550

119150

254

307

353

396420

448

391

483

589

497 508

60 69

14 24 2949 37 40

55 5236 35

17

WV Drug Overdose Deaths by Year & Manner2001-2013 Occurrences

All (inc. suicides and homicides) AccidentUndetermined

Deaths

3Data Source: WV Health Statistics Center, Vital Statistics System

Drug Overdose Rates by State

4

Prevalence of Illicit Drug Dependence

5

Illicit Drug Dependence in the Past Year Among Persons Aged 12 or Older by StatePercentages, Annual Averages Based on 2010 and 2011 NSDUH’s

2.02-2.54

1.89-2.01

1.78-1.88

1.63-1.77

1.39-1.62

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, NSDUH, 2010 (Revised March 2012) and 2011

Percentage of Persons

WV versus US

6

Centers for Disease Control and Prevention. Prevention Status Reports 2013: Prescription Drug Overdose-West Virginia. Atlanta, GA: US Department of Health and Human Services; 2014

Trend Analysis

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130

50

100

150

200

250

300

350

400

450

73 7596

130 138

175 177188

177

219

246224

197

139

168190

237

268

300312

333

302

349

410

344 353

WV Drug Overdose Deaths by Year & Sex2001-2013 Occurrences

Females Males

Deaths

7Data Source: WV Health Statistics Center, Vital Statistics SystemNote - 2012 and 2013 Preliminary

Trend Analysis

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130%

10%20%30%40%50%60%70%80%90%

100%

73 75 96 130 138 175 177 188 177 219 246 224 197

139 168 190 237 268 300 312 333 302 349 410 344 353

WV Drug Overdose Deaths by Year & Sex as a % of Total

2001-2013 Occurrences

Females Males

% of Deaths

8Data Source: WV Health Statistics Center, Vital Statistics SystemNote - 2012 and 2013 Preliminary

Demographic Analysis

0-19 20-29 30-39 40-49 50-59 60+0

100

200

300

400

500

600

17

159

240

349

211

85

21

268

514 511

364

77

WV Drug Overdose Deaths by Age-Group & Sex2009-2013 Occurrences

Females Males

Deaths

Avg. Age Males: 41.2Avg. Age Females 42.5Avg. Age Both Sexes 41.7

9Data Source: WV Health Statistics Center, Vital Statistics System* - 2012 and 2013 Preliminary

Drug Overdose Deaths by Month

Febru

ary

Marc

hApril

May

June

July

August

September

October

November

December

0

50

100

150

200

250

300

228244 236

223 223 227 227

263

227249 243

2009-2013 WV Occurrences*

Deaths

Average Number of Deaths per Month this time period - 47


Geographic

11

Trend Analysis – Major Selected Drugs

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130

50

100

150

200

250

WV Drug Overdose Deaths for Selected Drugs2001-2013 Occurrences by Year

Alprazolam OxycodoneDiazepam MethadoneHydrocodone CocaineMorphine Fentanyl

Deaths


Trend Analysis – 8 Commonly Involved

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130

50

100

150

200

250

WV Drug Overdose Deaths by Selected Drug Involved2001-2013 Occurrences by Year

Alprazolam Oxycodone DiazepamMethadone Hydrocodone FentanylHeroin Oxymorphone

Deaths


Trend Analysis – Five Prescription Opiates

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130

50

100

150

200

250

WV Drug Overdose Deaths for SelectedPrescription Opiates (Pharmaceuticals)

2001-2013 Occurrences by Year

Oxycodone Methadone Hydrocodone

Fentanyl Oxymorphone

Deaths

14

Data Source: WV Health Statistics Center, Vital Statistics System* - 2012 and 2013 Preliminary

Trend Analysis – 6 Prescription Non-opiates

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130

50

100

150

200

250

WV Drug Overdose Deaths for Selected Prescription Non-Opiate Drugs (Pharmaceuticals)


Alprazolam Diazepam Gabapentin

Citalopram AmitriptylineDeaths

15


Trend Analysis – Some drugs trend together

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130

50

100

150

200

250

WV Drug Overdose Deaths for Selected Opiates and Benzodiazepines


AlprazolamOxycodoneDiazepamHydrocodoneD

eaths

16


Trend Analysis – Other Major Players

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130

20

40

60

80

100

120

140

160

180

200

WV Drug Overdose Deaths for Heroin, Cocaine, and Amphetamines (Inc. Meth-)


Heroin Cocaine

Amphetamine (inc. Meth)Deaths

17


Trend Analysis

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130

50

100

150

200

250

WV Drug Overdose Deaths for Heroin, Oxycodone, and Hydrocodone


Heroin Oxycodone Hydrocodone

Deaths

18


Trend Analysis

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130

20

40

60

80

100

120

140

160

9 7 5 10 14 1122

38 38 3441

67

155

WV Heroin-Related Drug Overdose Deaths for 2001-2013, Occurrences by Year

Heroin

Deaths

19


OPIOIDS

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130

20

40

60

80

100

120

140

160

180

9 7 510

14 11

22

38 3834

41

67

155

5 4 49

1410

22

34 3732

41

66

154

4 3 1 1 0 1 04 1 1 0 1 1

WV Heroin-Related Overdose Deathsby Year & Manner

All (inc. suicides and homicides) Accident Undetermined

Deaths


OPIOIDS

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130

10

20

30

40

50

60

70

9

17

36

46

54

39

6057

49

44

51

32

37

9 10

35

44

52

38

57 56

4239

47

32

37

0

5

1 0 1 1 2 1

5 53

0 0

WV Fentanyl-Related Overdose Deathsby Year & Manner


Deaths


OPIOIDS

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130

20

40

60

80

100

120

140

160

180

200

0 0 0 2 0 16

14 17

77

181

72

31

0 0 0 2 0 06

14 16

71

177

71

27

0 0 0 0 0 1 0 0 1 5 3 1

WV Oxymorphone-Related Overdose Deathsby Year & Manner

All (inc. suicides and homicides)

Accident

Undetermined

Deaths


OPIOIDS

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130

50

100

150

200

250

3949 46 46

58

83

112

140 141

223 223

182 184

19

3541 44

54

72

99

131 128

203209

172178

18 142 0 2

104 9 10 13 9 8 4

WV Oxycodone-Related Overdose Deathsby Year & Manner

All (inc. suicides and homicides)AccidentUndetermined

Deaths


OPIOIDS

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130

10

20

30

40

50

60

70

80

11

20

26

38

50

62

68

48

4339

45

54

45

6

11

22

33

47

53

62

44

3835

43

51

42

26

4 42

75

3 41 0

2 2

WV Morphine-Related Overdose Deathsby Year & Manner


Deaths


OPIOIDS

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130

20

40

60

80

100

120

140

160

180

31 33

5344

61

87

72

86

97

138

171

142

123

23 24

5042

52

80

64

7785

126

152

132

117

7 71 2 3 4 3 4 7 8

124 2

WV Hydrocodone-Related Overdose Deathsby Year & Manner


Deaths


OPIOIDS

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130

20

40

60

80

100

120

140

160

39

83

71

116120

141

108

95

7883

6165

54

23

56

71

109116

129

100

90

72

81

57 5853

12

22

06 4

106 3 5

1 2 50

WV Methadone-Related Overdose Deathsby Year & Manner


Deaths


ANTI-ANXIETY

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130

50

100

150

200

250

30 27

42

56

40

80

155

186

134

175

239228

192

16 19

4048

32

69

139

172

117

158

222213

185

13 81 1 3 6 8 9 13 14 9 10

3

WV Alprazolam-Related Overdose Deathsby Year & Manner


Deaths


ANTI-ANXIETY

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130

20

40

60

80

100

120

140

160

4145

7481 82

99

149

123

108 105

151 153

107

2833

6773 73

89

137

114

91 91

134

145

104

8 11

2 3 3 59

513 12 10

4 3

WV Diazepam-Related Overdose Deathsby Year & Manner

All (inc. suicides and homicides)

Accident

UndeterminedDeaths


ANTI-DEPRESSANTS

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130

10

20

30

40

50

60

70

15

22

18

2826

20

32

21

43

47 48

63

40

107

16

2321

11

28

18

31 30

37

54

36

3

11

0 1 2

63 3

8

13

5 53

WV Citalopram-Related Overdose Deathsby Year & Manner


Deaths


ANTI-DEPRESSANTS

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130

5

10

15

20

25

30

35

40

16 1615

2827

22

2628

24

17

28

34

28

97

13

17

22

16

2122

13 13

2123

26

35

1

5

13

23

7

45

8

2

WV Amitriptyline-Related Overdose Deathsby Year & Manner


Deaths


STIMULANTS

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130

5

10

15

20

25

30

35

40

45

12 2 2

8

2

6

34

1817

19

40

02 2 2

7

2

53

2

1817

19

39

10 0 0

10 0 0 0 0 0 0

1

Amphetamine- or Methamphetamine-Related Overdose Deaths by Year & Manner


Deaths


STIMULANTS

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130

20

40

60

80

100

120

23

36

57

70

84

9791

70

61

73

82

70

82

11

22

55

67

80

92 90

6660

69

82

67

79

914

2 2 3 40

40 2 0 2 2

WV Cocaine-Related Overdose Deathsby Year & Manner


Deaths


OTHER DRUGS

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130

10

20

30

40

50

60

70

2 20 0 1 0 1 2 2 3

11

36

61

0 1 0 0 1 0 0 1 2 2

9

32

57

0 1 0 0 0 0 1 1 0 0 13 2

WV Gabapentin-Related Overdose Deathsby Year & Manner


Deaths


FATAL SECONDARY EFFECTS

TRANSPORTATION: 458 FATAL CRASHES (2004-5) WITH DRUG IMPAIRED OPERATORS (28.4%)*

WORK-PLACE FATAL INJURY ASSOCIATED WITH DRUG IMPAIRMENT (1999-2008: 3.5%)**

PEDIATRIC DEATHS AND PHARMACEUTICAL ABUSE? (SUID, CANNOT EXCLUDE EXTERNAL)

* MMWR: VOL. 55/NO. 48; DECEMBER 8, 2006** DATA SOURCE: WV HEALTH STATISTICS CENTER, VITAL STATISTICS SYSTEM

34

GENERAL OBSERVATIONS*RATE OF FATAL OVERDOSES ROSE DRAMATICALLY

FROM 1999 THROUGH 2007.

REMAINED STEADY IN 2007 - 2009. WHY?

BEGAN INCREASING AGAIN IN 2009 – 2011,MOSTLY DUE TO OXYMORPHONE ABUSE (OPANA®).

2012-- OXYMORPHONE DEATHS HAVE DECLINED, BUT NOW A HUGE INCREASE IN HEROIN OVERDOSE FATALITIES.

* INFORMATION PROVIDED BY DR. JIM KRANER, WV CHIEF TOXICOLOGIST

35

ROUTINE ENCOUNTERS 2012*

ETOH/DRUGS AS CONTRIBUTORY FACTORMVAs, ATVs, Tractors, Suicide, HomicideCOMMONLY SEE BZD + OPIOID +/- ETOHVery rarely a single agent outside of suicidesRoute of administration/bioavailabilityUNUSUALLY COMMON GABAPENTIN, CITALOPRAM, QUETIAPINE, AND PHENERGANBATH SALTS, SYNTHETIC THC, AIR DUSTERHUGE DISPENSE # PER BOPVA, border counties, fail to report, Rx after deathDOCTOR SHOPPING (>5/Y); NEEDS DEFINITION* PERSONAL OBSERVATIONS, AL MOCK MD

36

Polypharmacy - Co-use Heroin and Fentanyl

37

2012 – 1 death - Monongalia

2013 – 4 deaths – Berkeley and

Jefferson

2014 – 5 deaths through July –

Wayne, Raleigh, Wood, Calhoun,

Berkeley

Sudden Unexplained Infant Deaths Rate / 100K live births; 1999 to 2007West Virginia and U.S.

US: *58.4/ 100K LIVE BIRTHSWV: **125.7/100K LIVE BIRTHS

* CDC, Center for Health Statistics; R=95 ** WV Center for Health Statistics; R=95

Nu

mb

er o

f in

fan

ts

wit

h N

AS

prevalence of maternal drug use/abuse (NAS) diagnoses in a single hospital

Used by permission: David Chaffin, MD; Marshall U. School of Medicine; 2009.

No bed-sharingBed-sharing

Bed-sharing in WV SUID2004-2005; N=64

N=45 (70%)

N=19

Source: CFRT, OCME-West Virginia

Infant Death and Drug (Ab)use

• Maternal/caretaker impairment–Impaired judgment–Neglect issues•CO-SLEEPING WITH DECREASED AROUSAL

• Opioid associated NAS: risk of SUID*

*Journal of Pediatrics, 117, 876–887; 1990.

the death toll of prescription drug abuse: statistics and analysis, past and present al mock, md,...

Documents

total drug deaths

drugrelated overdose

number of deaths

males deaths

accidental deaths

female deaths

drug use

named drug