Alarming Rise Alarming Rise in Fatal in Fatal

Unintentional Unintentional Drug Drug

OverdosesOverdoses in Ohio in Ohio

Ohio Department of HealthViolence and Injury Prevention Program

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Number of deaths from MV traffic and Number of deaths from MV traffic and unintentional poisonings by year, Ohio unintentional poisonings by year, Ohio

1999-20071999-2007***Source: ODH Office of Vital Statistics

For first time, in 2006 unintentional poisoning exceeds MV traffic as

the overall leading cause of injury death in Ohio.

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Percentage change in number of annual deaths Percentage change in number of annual deaths for leading causes of injury, by mechanism and for leading causes of injury, by mechanism and

intent - Ohio, 1999 to 2006intent - Ohio, 1999 to 2006111Source: Ohio Dept of Health, Office of Vital Statistics

Increase from 369 deaths in 1999

to 1,308 in 2006

Unt=unintentional*all intents

Amounts to 3.6 deaths per day

in 2006

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Epidemics of unintentional drug overdoses in Ohio, Epidemics of unintentional drug overdoses in Ohio, 1979-20061979-20061,2,31,2,3

Source: 1WONDER (NCHS Compressed Mortality File, 1979-1998 & 1999-2005) 22006 ODH Office of Vital Statistics, 3Change from ICD-9 to ICD-10 coding in 1999 (caution in comparing before and after 1998 and 1999) 4

Crack Cocaine

Prescription Drugs

Heroin (1973-75)

Number of specific drug mentions among Number of specific drug mentions among unintentional fatal drug poisonings, Ohio, 2000-unintentional fatal drug poisonings, Ohio, 2000-

2007200711 1Source: ODH Office of Vital Statistics

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*includes only cases where no other drug/medicament than other/unspecified is listed as contributing cause of death

Prescription opioids include other opioids, methadone, other synthetic narcotics, and other/unspecified narcotics

Percent change in number of unintentional drug Percent change in number of unintentional drug poisoning deaths in which drug is mentioned, poisoning deaths in which drug is mentioned,

Ohio, from 2000 to 2007Ohio, from 2000 to 2007111Source: ODH Office of Vital Statistics

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Prescription opioids include other opioids, methadone, other synthetic narcotics, and other/unspecified narcotics

*includes only cases where no other drug/medicament than other/unspecified is listed as contributing cause of death

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Prescription Narcotic and Other/Unspecified Poisoning Death Rates/100,000

  Total Unt. Drug PoisoningsUnt. Prescription Opioid and

Other/Unspecified Only

No.

Avg. Annual

Rate

Ratio of County to State Rate No.

Avg. Annual

Rate

Ratio of County to State Rate

MONTGOMERY 785 17.9 2.4 532 12.1 2.5SCIOTO 100 16.4 2.2 87 14.1 2.9VINTON 15 14.2 1.9 12 11.4 2.4

CLINTON 45 13.4 1.8 36 10.8 2.2JACKSON 34 12.8 1.7 30 11.4 2.4

TRUMBULL 221 12.6 1.7 178 10.1 2.1ROSS 74 12.4 1.7 63 10.6 2.2

JEFFERSON 66 11.6 1.6 54 9.5 2.0CRAWFORD 40 11.0 1.5 36 9.9 2.0

HARDIN 28 11.0 1.5 24 9.5 2.0ADAMS 24 10.7 1.4 20 9 1.9

 Total Ohio 6,862 7.5   2,483 4.9  

Ohio Counties with Highest Unintentional Drug Poisoning Death Rates, 2000-07*

*Source: Ohio Vital Statistics

Contributing FactorsContributing Factors

SupplySupply DemandDemand

““Legal”Legal” Growth in Overall Rx Drug UseGrowth in Overall Rx Drug Use New Clinical Rx Pain Management New Clinical Rx Pain Management

Guidelines in 1997 – compassionate Guidelines in 1997 – compassionate chronic pain managementchronic pain management

Pressure to satisfy “customers” in HCPressure to satisfy “customers” in HC

““Illegal”Illegal” Widespread Diversion of Rx Drugs Widespread Diversion of Rx Drugs

through multiple channels:through multiple channels: Internet “pharmacies”Internet “pharmacies” ““Pill mills” and unscrupulous prescribersPill mills” and unscrupulous prescribers

Substance Substance Misuse/Abuse Misuse/Abuse DiversionDiversion Doctor ShoppingDoctor Shopping

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1In oral morphine equivalents using the following assumptions: (1) All drugs other than fentanyl are taken orally; fentanyl is applied transdermally. 2) These doses are approximately equianalgesic: morphine: 30 mg; codeine 200 mg; oxycodone and hydrocodone: 30 mg; hydromorphone; 7.5 mg; methadone: 4 mg; fentanyl: 0.4 mg; meperideine: 300 mg.

2Source: DOJ, DEA, ARCOS reports

Distribution of scheduled opioids1 in grams per 100,000 population by drug, Ohio, 1997 to 20072

What is Diversion?What is Diversion? The unlawful channeling of regulated The unlawful channeling of regulated

pharmaceuticals from medical sources to pharmaceuticals from medical sources to the illicit marketplace.the illicit marketplace.

Can occur along all points in the drug Can occur along all points in the drug delivery processdelivery process Manufacturing siteManufacturing site Wholesale distributorWholesale distributor Physician/prescriberPhysician/prescriber Dispensing institutionDispensing institution Retail PharmacyRetail Pharmacy HospitalsHospitals PatientPatient 11

Methods of DiversionMethods of Diversion Theft from Manufacturers, Pharmacies, Theft from Manufacturers, Pharmacies,

Homes, Hospitals, Nursing homes, etc.Homes, Hospitals, Nursing homes, etc. Internet SalesInternet Sales Doctor's Office or Phone Service scamDoctor's Office or Phone Service scam Phony Prescription Call-InPhony Prescription Call-In Prescription Forgery / AlterationPrescription Forgery / Alteration Illicit Drug Prescribing (e.g., “Pill Mills”) Illicit Drug Prescribing (e.g., “Pill Mills”) Deception of PrescribersDeception of Prescribers

Doctor-ShoppingDoctor-Shopping Emergency Room HoppingEmergency Room Hopping

Deception by PrescribersDeception by Prescribers Theft by healthcare professionals in hospitals, Theft by healthcare professionals in hospitals,

etc.etc.12

Diversion: A Lucrative Diversion: A Lucrative BusinessBusiness

Pharmacy PricePharmacy Price Street ValueStreet Value

$.09 to $.13 per mg$.09 to $.13 per mg $7-8 per 80-mg tablet$7-8 per 80-mg tablet $750 for 100 80-mg $750 for 100 80-mg

tabletstablets

$1 per mg$1 per mg $80 per 80-mg $80 per 80-mg

tablettablet $6,000-8,000 for $6,000-8,000 for

100 80-mg tablets100 80-mg tablets

13Source: DrugStory Factsheet: Abuse of Prescription Painkillers

OxyContin®

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Exposure

Rx Drug Misuse/Abuse

Fatal Overdose

Contributing Factors

Recent study suggests that fatal overdose problem is Recent study suggests that fatal overdose problem is mixed.mixed.

93% of Rx drug deaths involved opioids93% of Rx drug deaths involved opioids Of these, only 44% had prescriptions for these drugsOf these, only 44% had prescriptions for these drugs 79% had used multiple substances (mean of 2) 79% had used multiple substances (mean of 2)

contributing to their fatal overdose. contributing to their fatal overdose. Other findings: Other findings:

21% obtained drugs from “Dr. Shopping”21% obtained drugs from “Dr. Shopping” 63% obtained drugs through “Diversion” (no 63% obtained drugs through “Diversion” (no

prescription)prescription) 95% had indicators of substance abuse95% had indicators of substance abuse

Study of Rx drug overdose deaths in WV using ME, PDMP and substance abuse treatment data1

1Source: Hall et al. Patterns of abuse among unintentional pharmaceutical overdose fatalities. JAMA 2008; 15

Risk Groups for Opioid Overdose*Risk Groups for Opioid Overdose*1.1. Pain patients:Pain patients:

Taking high doses of medication. Taking high doses of medication.

Taking medications incorrectly.Taking medications incorrectly.

2.2. Nonmedical pain medication users and those with a Nonmedical pain medication users and those with a history of substance abusehistory of substance abuse

WV study: 95% had indicators of substance abuseWV study: 95% had indicators of substance abuse

3.3. PersPersons who have already experienced a drug ons who have already experienced a drug overdose.overdose.

4.4. Persons taking multiple medications, especially Persons taking multiple medications, especially multiple CNS depressants, simultaneouslymultiple CNS depressants, simultaneously

WV study:WV study: 79% used multiple substances that contributed to OD 79% used multiple substances that contributed to OD

*Sanford K. Findings and Recommendations of the Task Force to Prevent Deaths from Unintentional Drug Overdoses in North Carolina, 2003. 16

Risk Groups for Opioid OverdoseRisk Groups for Opioid Overdose11

Persons with chronic health problems such as: Persons with chronic health problems such as:

COPD, emphysema, respiratory illness, heart problems, COPD, emphysema, respiratory illness, heart problems, renal dysfunction or hepatic disease. renal dysfunction or hepatic disease.

Using after a period of abstinence (e.g., after SA Using after a period of abstinence (e.g., after SA treatment or treatment or recently released prisoner population)recently released prisoner population)

Patients newly starting methadone for pain control Patients newly starting methadone for pain control and patients who have switched to methadone and patients who have switched to methadone after treatment with other strong opioid pain after treatment with other strong opioid pain relieversrelievers

1Sanford K. Findings and Recommendations of the Task Force to Prevent Deaths from Unintentional Drug Overdoses in North Carolina, 2003.

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Other Risk FactorsOther Risk Factors Low incomeLow income

Medicaid recipients are more likely to be prescribed Medicaid recipients are more likely to be prescribed narcotics and to die from prescription drug overdosesnarcotics and to die from prescription drug overdoses11

Lower educational attainmentLower educational attainment and increased poverty in and increased poverty in decedent's county of residencedecedent's county of residence were both associated with were both associated with greater death rates in a dose-responsegreater death rates in a dose-response fashion.fashion.22

Lack of substance abuse treatmentLack of substance abuse treatment GenderGender

Males- Most deathsMales- Most deaths33

Females – Fastest growing groupFemales – Fastest growing group Drug/medication poisoning death rates for females increased Drug/medication poisoning death rates for females increased

133% from 1999 to 2005 in the U.S, versus 75% for males.133% from 1999 to 2005 in the U.S, versus 75% for males.44

Sources: 1ASTHO (Association of State and Territorial Health Officials) Report: Prescription Drug Overdose: State Health Agencies Respond http://www.astho.org/pubs/RXReport_Web.pdf 2Hall et al. Patterns of abuse among unintentional pharmaceutical overdose fatalities. JAMA 2008.3Ohio Vital Statistics 4CDC WONDER

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What we know so far..What we know so far.. Regulated prescription drugs taken mostly by mouth Regulated prescription drugs taken mostly by mouth

can produce a larger overdose epidemic than illicit can produce a larger overdose epidemic than illicit drugs of uncertain strength taken intravenously.drugs of uncertain strength taken intravenously.

Ohio’s rates are greater than US; particularly in Ohio’s rates are greater than US; particularly in southern OHsouthern OH

Increased access to opioid medications from Increased access to opioid medications from late‘90’s onlate‘90’s on

White males at highest risk for opioid OD but white White males at highest risk for opioid OD but white females are the fastest growing group.females are the fastest growing group.

Males aged 45-54 have the highest death rates of Males aged 45-54 have the highest death rates of all. all.

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What we know so far..What we know so far.. Most deaths are associated with opioids/narcotics.Most deaths are associated with opioids/narcotics.

Most rapid increases associated with synthetic opioids Most rapid increases associated with synthetic opioids (e.g., Methadone) (e.g., Methadone)

Multiple substance use (polypharmacy) is a factor in Multiple substance use (polypharmacy) is a factor in many of these deaths, complicating issue. many of these deaths, complicating issue. Polypharmacy is a risk factor for fatal overdose.Polypharmacy is a risk factor for fatal overdose.

Single drug overdoses more likely to be opioids Single drug overdoses more likely to be opioids (especially those with long half-life or controlled release)(especially those with long half-life or controlled release)

Diversion of RXs, Dr. shopping & substance abuse play Diversion of RXs, Dr. shopping & substance abuse play a large role.a large role.

We need additional information about the substances We need additional information about the substances responsible and how they are being used. responsible and how they are being used.

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Potential PartnersPotential Partners Community organizationsCommunity organizations Poison Control CentersPoison Control Centers Pharmacists/Pharmacy Pharmacists/Pharmacy

BoardBoard Coroners/Medical ExaminersCoroners/Medical Examiners ToxicologistsToxicologists Researchers/AcademicsResearchers/Academics Health Insurance CompaniesHealth Insurance Companies Law enforcementLaw enforcement Local Health DepartmentsLocal Health Departments Hospitals/Trauma CentersHospitals/Trauma Centers EMSEMS ODADASODADAS

ODMH Mental health and substance

abuse professionals Emergency Nurses

Association Ohio Hospital Association Ohio Osteopathic Association Ohio State Medical Assn Ohio Substance Abuse Ohio Chapter, ACEP Monitoring (OSAM) Network Pain and palliative care

specialists/advocates Others?

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For More Information…For More Information… Hall AJ, Logan JE, Toblin RL, et alHall AJ, Logan JE, Toblin RL, et al. . Patterns of abuse among Patterns of abuse among

unintentional pharmaceutical overdose fatalitiesunintentional pharmaceutical overdose fatalities. JAMA . JAMA 2008;300(22):2613-20. 2008;300(22):2613-20. http://jama.ama-assn.org/cgi/content/full/300/22/2613http://jama.ama-assn.org/cgi/content/full/300/22/2613

ASTHO (Association of State and Territorial Health Officials) ASTHO (Association of State and Territorial Health Officials) Report: Report: Prescription Drug Overdose: State Health Agencies Prescription Drug Overdose: State Health Agencies RespondRespond http://http://www.astho.org/pubs/RXReport_Web.pdfwww.astho.org/pubs/RXReport_Web.pdf

Drug Abuse in America:  Prescription Drug Diversion.Drug Abuse in America:  Prescription Drug Diversion.  Trend   Trend Alert:  Critical Information for State Decision-makers.  The Council Alert:  Critical Information for State Decision-makers.  The Council of State Governments.  April 2004 of State Governments.  April 2004 http://www.csg.org/pubs/Documents/TA0404DrugDiversion.pdfhttp://www.csg.org/pubs/Documents/TA0404DrugDiversion.pdf

Subscribe for OSAM-O-Grams Subscribe for OSAM-O-Grams –– Wright State University & Wright State University & University of Akron University of Akron http://http://www.med.wright.edu/citar/osam.htmlwww.med.wright.edu/citar/osam.html

ODH Factsheet ODH Factsheet http://healthyohioprogram.org/ASSETS/45E86204619D4F0B813F82D77D5FA500/Poison.pdfhttp://healthyohioprogram.org/ASSETS/45E86204619D4F0B813F82D77D5FA500/Poison.pdf

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