The Grand Unifying Theory of Poisoning/Overdose

SurveillanceA Collaborative Effort

June 9, 2013

Motor Vehicle Traffic, Poisoning, and Drug Poisoning Death Rates

US 1980-2010

1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 20100

5

10

15

20

25

Motor Vehicle Traffic

Poisoning

Drug Poisoning (Overdose)

Year

Dea

ths

per 1

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opul

atio

n

NCHS Data Brief, December, 2011, Updated with 2009 and 2010 mortality data

Opioid Analgesics:The National Picture

• Fastest growing drug problem in United States• Enough prescription painkillers prescribed in

2010 to medicate every American adult around-the-clock for a month

• ~12 million Americans report misuse of opioid analgesics within past year (2010) >16,000 overdose deaths from opioid analgesics (2010)

• Considered an “epidemic”

Background & History

Background & History• Safe States Poisoning Workgroup- 2008• Safe States formation of Injury Surveillance Workgroup

(ISW-7)• Publication of ISW7- May 2012• CDC/Safe States/CSTE conferences 2012• CSTE Drug Overdose-

– Willing and wanting to test ISW7 indicators– Providing organizational base for effort

• SQI Year 2 focus on poisoning• Real partnership with Safe States – liaison/driving force

• Scott Proescholdbell

Why CSTE Overdose subcommittee choose this project

• Increased attention by States to report and track drug overdose

• Lack of consistent definitions and indicator • Variations across States and local level • Recognizing 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

Timeline• August- 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- Data results & write up of methods and

process for Special Emphasis Report• Spring- April CDC mtg on poisoning for Core states

Next Steps

Next Steps• June- Presentations (Safe States & CSTE)• July- development of Special Emphasis

Report and pilot testing• Transition from mortality to morbidity (SQI

protocol)• Additional testing of codes, development of

potential indicators and position statements

Introduction to Mortality Surveillance: Levels 1-3

Daniella Bradley O’Brien

Outline• Definition of terms

– What is a drug poisoning (overdose) death?– What is an ICD Code?

• What ICD-10 codes are used?• Intent• Underlying/Multiple Cause of Death

• Surveillance levels 1-4• How to surveil drug poisoning deaths

Definition of Terms

International Classification of Diseases-10th classification (ICD-10)

• Standard diagnostic tool for epidemiology, health management and clinical purposes

• Monitors the incidence and prevalence of diseases and other health problems

• Defines the universe of diseases, disorders, injuries and other related health conditions. It allows for:– sharing and comparing health information between hospitals, regions,

settings and countries; and– data comparisons in the same location across different time periods.

• Does not always identify specific drugs causing death

External Cause of Injury Mortality Matrix

External Cause of Injury Mortality Matrix

Mechanism of Death

Intent of Death (Based ICD-10)

Unintentional Suicide Homicide UndeterminedLegal

Intervention/war

Poisoning X40-X49 X60-X69 X85-X90,U01.6-.7 Y10-Y19 Y35.2

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

Underlying ICD-10 Drug Poisoning Codes

Medical Examiner/Coroner: Determining cause and manner of death

Death sceneinvestigation

Autopsy ToxicologyDetermination of cause and

manner of death

Context• Paraphernalia• Pill bottles• Witness

accounts

Physical findings• Heart muscle

(e.g. damaged by cocaine use)

• Asthma

Drugs• Active (capable of

causing death)• Synergistic • Contributing• Present, not active

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. Acute intoxication

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):

Due to the combined effects of b. Heroin and Oxycodone 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.

Asthma

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)

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

Acute and Chronic Substance Abuse44. IF TRANSPORTATION INJURY, SPECIFY Driver/Operator Passenger Pedestrian Other (Specify)

To B

e C

ompl

eted

By:

ME

DIC

AL

CE

RTI

FIE

R

X

Part IIOther significant conditions contributing to death

Part I Lines a-d Causes of death are entered sequentially starting with immediate cause and ending with the underlying cause.

How injury occurredGenerally determines external cause of death.

Manner

Death Certificate Literals• “Literals” are the exact text entered on the death

certificate

• Specialized software reads the literals and automatically codes both underlying and multiple cause of death

Exact words from Part I, Part II, manner and how the injury occurred

Mortality Medical Data

System

Automated coding of causes of death

Death Certificate

Cause of death

Part 1a. _Acute Intoxicationb. Due to combined___

effects of heroin and oxycodone. _________________

d. _________________

Part 2 :Asthma

Manner: AccidentDescribe how injury occurred:Acute and Chronic Substance Abuse

Cause of death by ICD-10 codes

UCOD: X42MCOD: X42, T40.1, T40.2,

CSTE Validation of ISW-7: Methods• 4 levels

– Level 1: Basic– Level 2: Multiple Cause– Level 3: Cross-Check– Level 4: Multi-stage

• Year 2010• Residents of each state

that died in state• 11 states/jurisdictions

Drug Poisoning Mortality Surveillance “Levels 1-4”Level 4:

Multi-Stage

Toxicology and

Literals

Level 1: Basic

Underlying cause of death file

Level 1: Basic Analysis ObjectiveLevel 4:

Multi-Stage

Toxicology and

Literals

Level 1: Underlying cause

with associated demograp

hics

Level 1: Basic Analysis

*Note: To obtain Death Certificate contact your city/state’s Office of Vital Statistics or agency equivalent responsible for the reporting, processing, and analyzing all vital events (births, deaths, etc.)

Required Resource: Death Certificate*

Obtain Underlying Codes

Use Underlying Codes:X40-X44, X60-X64, X85, Y10-Y14, Y40-Y59,

[F11-F16] (.0), F19.0

Tabulate results for Level 1

Level 1: Basic AnalysisDemographics X40 X41 X42 X43 X44

X40-X44 Total

  N % N % N % N % N % N %Total      87 100%     87  100% Gender                   Male        54 62%        54 62% Female        33 38%        33 38% Race/Ethnicity                   Black Non-Hispanic        27 31%          27 31% White Non-Hispanic        29 33%          29 33% Hispanic        28 32%          28 32% Asian/Pacific Islander          1 1%          1 1% American Indian/ Alaskan Native          1 1%          1 1% All Other          1 1%          1 1% Age Group         0-14          1 1%          1 1% 15-24          10 11%          10 11% 25-34          15 17%          15 17% 35-44          20 23%          20 23% 45-54          18 21%          18 21% 55-64          10 11%          10 11% 65-84          6 7%          6 7% 85+          4 5%          4 5%

Level 1: Summary• Report on poisoning by intent

• Provide demographic profile of the decedents– Age– Gender– Race/Ethnicity– Residential information available but not

collected/tested as part of CSTE validation of ISW-7

Level 2: Multiple Cause Objective Level 4:

Multi-Stage

Toxicology and

Literals

Level 1: Underlying cause

with associated demograp

hics

T-codes • Are multiple cause codes

• Identify specific drug or substance

• For poisoning and toxic effects in ICD-10 these are T36-T65

Multiple Cause T-Codes by Drug TypeExample drugs Drug category ICD-10 code“Morphine”“Oxycodone”“Hydrocodone”

Natural and semi-synthetic opioid analgesics (aka “Other opioids”) T40.2

“Methadone” Methadone T40.3

“Fentanyl”“Propoxyphene”“Meperidine”

Synthetic opioid analgesics, excluding methadone(aka “Other synthetic narcotics”)

T40.4

“Opiates”“Opioid”“Narcotics”

Other and unspecified narcotics T40.6

“Cocaine” Cocaine T40.5

“Heroin” Heroin T40.1

“Alprazolam” Benzodiazepines T42.4

“Methamphetamine” Methamphetamine T43.6

“Drugs”“Polypharmacy” Other and unspecified drug(s) T50.9

Opioid analgesics

Level 2: Multiple Cause AnalysisRequired Resource: Death Certificate*

Obtain Multiple Cause Codes:1. Underlying Cause Codes2. Contributing Cause Codes

Tabulate results for Level 2

Use Multiple Cause Codes:X40-X44, X60-X64, X85, Y10-Y14, Y40-Y59,

[F11-F16] (.0), F19.0, T36-T50.9

Level 2: Multiple Cause CodesX40 X41 X42 X43 X44

Total X40-X44

N % N % N % N % N % N %T42.4:Benzodiazepines 10 9% 10 9%T40.1: Heroin 20 18% 20 18%T40.2: Other opioids (Incl:Codeine, Oxycodone,Morphine) 35 32% 35 32%T40.3 Methadone 10 9% 10 9%

T40.4:Other synthetic narcotics(Incl:Pethidine) 1 1% 1 1%T40.5: Cocaine 15 14% 15 14%T40.6:Other and unspecified narcotics 7 6% 7 6%T50.9: Other and unspecified drugs, medicaments and biological substances 10 9% 10 9%T50.9: Other and unspecified drugs, medicaments and biological substances **Only T50.9 listed, no other T-codes (between T30.0 and T50.8) listed** 2 2% 2 2%

* This row includes any mention of T50.9, where it can be listed alone or as one of several T-codes listed.

** This row includes only occurrences where T50.9 is the only T-code listed (between T36.0 and T-50.8). This is a subset of the Any Mention of T50.9 row.

Level 2: Summary

• Report major categories of drug types by intent

Level 3: Cross-Check ObjectiveLevel 4:

Multi-StageToxicology and Literals

Level 3: Literal text from death certificate

Level 2: Drug Specificity (T-

Codes)

Level 1: Underlying cause with associated

demographics

Uses of literal text• Identifying specific substances in “other

specified” ICD-10 drug categories

• Monitoring increases in deaths associated with drug substances not specifically identified in ICD-10

• Potential for use as a sentinel surveillance system for new drugs associated with deaths

Level 3: Cross-Check AnalysisRequired Resource: Death Certificate*

Obtain Multiple Cause Codes:1.Underlying Cause Codes2. Contributing Cause Codes

Tabulate results for Level 3

Cross-check Death Certificate Literals against Multiple Cause Codes

Use Multiple Cause Codes:X40-X44, X60-X64, X85, Y10-Y14, Y40-Y59, [F11-F16] (.0),

F19.0, T40.1,T40.2,T40.3,T40.4,T40.6,T43.6,T50.9

Level 3: Cross-Check Analysis

Part 1a Part 1b Part 1c Part 2Underlying Code

Multiple/ Contributing Codes

How Injury Occurred

Acute Oxycodone Intoxication

X42 T40.2 Ingested Medication

Level 3 Summary• Specificity of literals

– ex: T40.2 Oxycodone/Hydrocodone/Morphine

• Determine how literals are coded in your state/jurisdiction

Introduction to Level 4:Multistage Analysis

Denise Paone

Drug overdose deaths – 4 “Levels”Level 4:

Toxicology and Literals

Level 3: Literal text from death certificate

Level 2: Drug Specificity (T-

Codes)

Level 1: Underlying

cause of death file

Definitions/Terms• Toxicology

– Collected and analyzed as part of death investigation

– Not always available

Level 4: Multistage AnalysisObjective & Methods

• Objective:– Compare toxicology results using ME

findings, with ICD-10 codes and literals found on death certificates

• Methods:– Restricted T-Codes to cases involving

opioids/unspecified

Level 4: MultistageRequired Resource: Death Certificate* + Medical

Examiner/Coroner files containing Toxicology Report

Comparison of Death Certificate Multiple Cause Codes with confirmed Toxicology data

Comparison of Death Certificate Literals with confirmed Toxicology data

Comparison of Death Certificate Multiple Cause Codes, confirmed Toxicology data and Literals

Tabulate results for Level 4 in table shell provided

Obtain Multiple Cause Codes:1. Underlying Cause Codes2. Contributing Cause Codes

Use Multiple Cause Codes:X40-X44, X60-X64, X85, Y10-Y14, Y40-Y59, [F11-F16] (.0), F19.0,

T40.1,T40.2,T40.3,T40.4,T40.6,T43.6,T50.9

Level 4: Multistage Analysis

Part 1a

Part 1b

Part 1c Part 2

Underlying Code

Multiple/ Contributing Codes

How Injury Occurred Toxicology

Acute intoxication by the combined effects of Oxycodone, Morphine, Diazepam, and Cocaine

X42- T40.2 T50.9

Benzoylecgonine, Diazepam, Oxazepam, Oxycodone, Temazepam

Level 4 Summary• Raises more questions than it answers?!

• Continue to refine this analysis

Acknowledgements• CSTE Overdose sub-committee members• Safe States Members• CDC Staff• NYC DOHMH