Opiate/opioid-Related Deaths in New Hampshire

Thomas A. Andrew, MD

Chief Medical Examiner

State of New Hampshire

A National Public Health Issue

• Since 2000 drug deaths increased 137%

• 200% increase in opioids deaths

• 2014: 47,055 drug deaths, representing a 1-year increase of 6.5%, from 13.8 per 100,000 in 2013 to 14.7 per 100,000 in 2014

• 2014: 28,647 opioid deaths, 61% of all drug deaths

• Opioid deaths increased 14% from 7.9 per 100,000 in 2013 to 9.0 per 100,000 in 2014

• Heroin death rates increased by 26% from 2013 to 2014 and have more than tripled since 2010, from 1.0 per 100,000 in 2010 to 3.4 per 100,000 in 2014

A National Public Health Issue

• States with statistically significant increases in drug death rate from 2013 to 2014: Alabama, Georgia, Illinois, Indiana, Maine, Maryland, Massachusetts, Michigan, New Hampshire, New Mexico, North Dakota, Ohio, Pennsylvania, and Virginia

A National Public Health Issue

• In 2014, the five states with the highest rates of drug overdose deaths:

– West Virginia (35.5 deaths per 100,000)

– New Mexico (27.3)

– New Hampshire (26.2)

– Kentucky (24.7)

– Ohio (24.6)

Age-Adjusted Drug Death Rate per 100,000

State

Deaths Population

Crude Rate Per

100,000

Age Adjusted Rate Per

100,000

West Virginia (54) 627 1,850,326 33.9 35.5

New Mexico (35) 547 2,085,572 26.2 27.3

New Hampshire

(33) 334 1,326,813 25.2 26.2

Kentucky (21) 1,077 4,413,457 24.4 24.7

Ohio (39) 2,744 11,594,163 23.7 24.6

Rhode Island (44) 247 1,055,173 23.4 23.4

Utah (49) 603 2,942,902 20.5 22.4

Pennsylvania (42) 2,732 12,787,209 21.4 21.9

Delaware (10) 189 935,614 20.2 20.9

Oklahoma (40) 777 3,878,051 20.0 20.3

Tennessee (47) 1,269 6,549,352 19.4 19.5

Wyoming (56) 109 584,153 18.7 19.4

Massachusetts

(25) 1,289 6,745,408 19.1 19.0

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

NEW HAMPSHIRE’S RANKING AMONG THE 50 STATES AND TERRITORIES

According to 2012-2013 NSDUH

12-17 yr 18-25 yr 26+ yr 18+ yr

2012-2013

NSDUH

NH

(%)

NH

Rank US (%)

NH

(%)

NH

Rank US (%)

NH

(%)

NH

Rank US (%)

NH

(%)

NH

Rank US (%)

30 Day Binge 8.1% 3rd 6.7% 49.0% 3rd 38.7% 23.1% 21st 22.2% 26.6% 17th 24.6%

30 Day

Marijuana 9.6% 6th 7.2% 27.7% 4th 18.9% 7.0% 13th 5.5% 9.8% 11th 7.4%

Past 30 Days

Illicit Drug Use 3.0% 32nd 3.4% 10.0% 1st 6.9% 2.6% 24th 2.8% 3.6% 17th 3.4%

Past Year Pain

Relief 4.9% 30th 5.0% 10.5% 14th 9.5% 3.2% 33rd 3.6% 4.2% 30th 4.5%

Alcohol Dep. Or

Abuse Past Year 4.6% 3rd 3.1% 19.2% 1st 13.7% 6.2% 24th 6.0% 7.9% 13th 7.1%

Drug

Dependence

Only Past Year 2.3% 6th 2.0% 7.4% 1st 5.4% 1.3% 30th 1.3% 2.1% 10th 1.9%

NH Drug Deaths 1995-2015*

*6 pending cases

Drug Deaths 2000-2015* by Age

Drug Deaths 2000-2015* by Sex

Drug Deaths 2000-2015* by Manner

Leading Agents in NH Drug Deaths

NH Top 5 2005-2012

2005 2006 2007 2008

Methadone Methadone Methadone Methadone

Cocaine Cocaine Cocaine Oxycodone

Oxycodone Oxycodone Oxycodone Cocaine

Diazepam Diazepam Diazepam “Heroin”

“Heroin” Fentanyl Morphine Diazepam

2009 2010 2011 2012

Methadone Methadone Oxycodone Heroin

Oxycodone Oxycodone Heroin Oxycodone

Cocaine Cocaine Methadone Methadone

“Heroin” Morphine Cocaine Cocaine

Citalopram Fentanyl Alprazolam Morphine

NH Top Five 2013-2015*2013 2014 2015

Heroin Fentanyl Fentanyl

Oxycodone Heroin Heroin

Cocaine Cocaine Cocaine

Fentanyl Methadone Oxycodone

Methadone Oxycodone Benzodiazepines

Single Agent Deaths (%)

Leading Single Agents of Death

2006 2007 2008 2009 2010

“Opiates” Methadone Heroin Methadone Methadone

Methadone “Opiates” Methadone Heroin Cocaine

Cocaine Cocaine Cocaine Oxycodone Oxycodone

2011 2012 2013 2014 2015*

Heroin Heroin Heroin Fentanyl Fentanyl

Oxycodone Methadone Fentanyl Heroin Heroin

Methadone Oxycodone/cocaine

Cocaine Methadone Methadone/oxycodone

Heroin

Fentanyl

Heroin and fentanyl seen together in 39 cases in 2014and 43 cases in 2015 to date

Fentanyl Deaths 2009-2015 by Month

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec TOTAL

2009 1 0 1 4 1 1 2 2 2 0 0 1 15

2010 2 0 2 2 2 4 2 1 0 1 2 1 19

2011 0 2 2 3 1 2 2 1 0 1 1 3 18

2012 2 1 1 0 2 2 1 0 0 1 1 1 12

2013 2 1 3 0 1 2 0 3 3 0 0 3 18

2014 6 8 9 9 10 10 4 8 9 27 23 29 152

2015 22 27 24 29 23 29 19 17 24 6* 2* --- 222

Rank State Number of Fentanyl seizures

1 Ohio 1245

2 Massachusetts 630

3 Pennsylvania 419

4 Maryland 311

5 New Jersey 238

6 Kentucky 232

7 Virginia 222

8 Florida 183

9 New Hampshire 177

10 Indiana 133

Total Fentanyl Seizures, 2014*

*Source: CDC Health Alert Network

October 26, 2015

*

*National Forensic

Laboratory Information System

Fentanyl• Synthetic opioid 10X more potent

than morphine

• Legitimate use: severe, chronic pain

• Trade names: Actiq, Duragesic, and Sublimaze

• Binds opiate receptors, driving up dopamine levels, producing euphoria and relaxation

FentanylMost often administered via injection, transdermal patch, or in lozenge form

Fentanyl

Potential risk of discarded patches or improperly stored lollipops

Abuse Potential

Illicit Fentanyl Production• Produced in clandestine laboratories

and mixed with (or substituted for) heroin in a powder form

• Mixing fentanyl with street-sold heroin or cocaine markedly amplifies potency and potential dangers

• Street names : Apache, China girl, China white, dance fever, friend, goodfella, jackpot, murder 8, TNT, as well as Tango and Cash

Illicit Fentanyl Analogues– Alpha-methyl Fentanyl

– First illicit derivative to appear on the streets

– Very simple modification of the fentanyl structure

– ~200 times as potent as morphine

– Acetyl Fentanyl

– Implicated in numerous deaths

– ~five times more potent than morphine

– CDC recommendations

• Increased vigilance by public health agencies, emergency departments, state laboratories, medical examiners, and coroners

• If fentanyl immunoassay is positive additional confirmation testing should include fentanyl and its analogs, including acetyl fentanyl

• 3-Methyl Fentanyl

– Latest derivative introduced onto the streets

– Up to 3000 times as potent as morphine

ACETYL FENTANYL

Drug Recognition• Color

– Pure white (sold as Persian White), to light tan (sold as Synthetic Heroin), to light brown (sold as Mexican Brown)

– Brown color comes from lactose which has been heated and has caramelized slightly

• Texture

– Street samples range from light, fine powder to coarse, cake-like, and crumbly, resembling powdered milk

• Odor

– Occasional medicinal or chemical odor, but not characteristic

• Packaging

– Sold like heroin in small zip-lock plastic bags and bindles

Source of Drug2008 2009 2010 2011 2012 2013 2014 2015*

RX 48 83 78 60 57 33 61 41

Illicit 45 63 68 103 61 80 215 286

Illicit/Rx 12 6 3 16 11 17 17 13

OTC 4 4 5 3 4 4 4 3

OTC/Rx 3 3 36 9 14 12 6 4

OTC/Illicit --- --- 3 1 11 8 11 4

Unk 3 1 1 9 0 33 7 3

All Three --- --- --- --- 6 6 6 0

NH Drug Deaths vs. Traffic Deaths 1995-2015*

In 2014, there were approximately one and a half times more drug overdose deaths in the United States than deaths from motor vehicle crashes

We Are Not Alone• Fatalities have increased in states reporting

large increases in fentanyl seizures

• Two of the top five, Ohio and Maryland, both reported sharp increases in fentanyl-related deaths in 2014

– Ohio: 92 in 2013 � 514 in 2014

– Maryland: 58 in 2013 � 185 in 2014

• Massachusetts currently investigating whether an abnormally sharp increase in opioid-related deaths in 2014 is attributable to fentanyl

• Florida recently reported 397 fentanyl fatalities in 2014, up from 185 in 2013

We Are Not AloneMaine*, 2015: 272 drug deaths, 31% more than in 2014 (208)

Continues a multi-year rise in deaths due to heroin and illicit fentanyl, sometimes in combination with each other

20% more deaths due to illicit fentanyl and acetyl fentanyl July-Dec vs. Jan-June

5% more deaths due to heroin in same period

Source: Marcella Sorg, PhD Margaret Chase Smith Policy Center, Univ. of Maine

More from Maine*

• 157/272 (58%) due either to heroin (107) and/or illicit fentanyl (74) or acetyl fentanyl (32) with a wide variety of co-intoxicant combinations with other drugs or alcohol

• 19 due to a combination of fentanyl and acetyl fentanyl

Source: Marcella Sorg, PhD Margaret Chase Smith Policy Center, Univ. of Maine

More From Maine*

Source: Marcella Sorg, PhD Margaret Chase Smith Policy Center, Univ. of Maine

Maine

Source: Marcella Sorg, PhD Margaret Chase Smith Policy Center, Univ. of Maine

We Are Not Alone• Cleveland, OH

– Fentanyl deaths have risen since November 2014

– The drug is clandestinely manufactured (not diverted from legitimate sources) and distributed by the same networks distributing heroin

– 2015: projected 80-85 fentanyl deaths, more than double 2014

– About half with heroin, a little less than half fentanyl alone and the rest fentanyl with something else

– “Our fentanyl overdoses tend to be a bit younger than the typical heroin overdose and we are seeing slightly more women (~1/3) with a slight majority from suburban communities" Tom Gilson, MD

Chief Medical Examiner

Latest from Cleveland• 89 fentanyl deaths in 2015 with approximately half

also having heroin detected

• January 2016 - 17 fentanyl deaths, 7 also having heroin

• We had our first fentanyl pill drug seizures this month AND THEY WERE MANUFACTURED TO LOOK LIKE OXYCODONE 30mg tablets.

• We think this was a result of oxycodone being more expensive than fentanyl in street sales.

• Might also give the false sense of comfort that a pharmaceutical pill is safe.

We Are Not Alone• Pittsburgh, PA

– “When you hear the phrase ‘heroin overdose,’ be aware that the ‘heroin’ could be almost anything.”

– 2013: 8 fentanyl related deaths, almost exclusively diverted pharmaceutical material, primarily patches

– January 2014: 16 deaths in Allegheny County with several additional deaths in the surrounding counties

– Offending “heroin” actually a white powder that was 1:1 heroin:fentanyl, and distributed in only two (“Bud Ice” & “Theraflu”) of the many different stamp bags that were out in the community

– “New kid on the block” here is acetyl fentanyl

• No acetyl fentanyl associated deaths in 2014

• 14 cases so far in 2015

Karl Williams, MDChief Medical Examiner

We Are Not Alone

• Alberta, Canada

– Population est. 4 million

– 2011: 6 fentanyl-related deaths, probably related to diverted prescription medication

– January-June 2015:145 fentanyl-related deaths

– Not related to diverted prescription fentanyl, but imported and illicit preparations

– Sometimes fentanyl is identified in isolation, many of the cases are combined with ethanol, cocaine, methamphetamine and/or heroin

Jeffery Gofton, M.D.Chief Medical Examiner

Naloxone• The Cleveland Experience

– Civilian distribution started in May 2013

– Since then, ~250 saves with reasonable documentation (number could be higher)

– 2014: law enforcement started to administer with additional saves

– Heroin fatalities did not decline from 2013 to 2014 (but it did not continue to rise)

– 2015: slight drop in mortality (195 to ~180 deaths) but still substantially higher than a decade ago

– “I see the bottom line as that the program is actually very successful but the problem is (for the time being) bigger than the solution.”

Economic Cost

• $1.84 Billion/year

– 2.8% GSP

• 10,000 people out of the workforce

• Cost to state and businesses

– Absenteeism

– Unfilled positions

– Public Safety

– Healthcare

Guidance that Drives Solutions

Treatment: http://nhtreatment.org/

Medication-Assisted Treatment

1 Death

9 in Rehab2,934

35 ED visits11,410

161 addicted52,486

461 recreational users – 150,286

Acknowledgment

Tym Rourke, MADirector, Substance Use Grantmaking ChairGovernor’s Commission on Alcohol and Drug Abuse Prevention, Treatment and Recovery