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The Office of the Chief Medical Examiner, Virginia Department of Health
Deaths from Heroin and Prescription Opiates in Virginia:
An Overview
William T. Gormley, MD, PhD, Chief Medical Examiner
Rosie Hobron, MPH, Forensic Epidemiologist
Data Sources: Office of the Chief Medical Examiner, Virginia Medical
Examiner Data System (VMEDS)
Office of the Chief Medical Examiner
Code of Virginia § 32.1-283 Investigation of deaths: obtaining consent to removal of organs, etc.; fees
Deaths from Heroin and Prescription Opiates
20042005200620072008200920102011201220132014*
0
50
100
150
200
250
0 4
19
10089
107
48
100
135
213 210
Number of Fatal Heroin Overdoses by Year,
2004-2014*
Year
Num
ber
of
Death
s
1 Fatal heroin overdoses may have one or more drug or poisons con-tributing to death.2 The number of fatal heroin overdoses in 2014 is estimated based upon data for January 1, 2014 to June 30, 2014.
2007 2008 2009 2010 2011 2012 2013 20140
100
200
300
400
500
600
389
422398
415
487
414
468
508
Number of Fatal Prescription Opioid Overdoses by Year, 2007-2014*
Year
Num
ber
of
Death
s
1 Heroin and prescription drug deaths are tallied separately. Where heroin and prescription opioids caused or contributed to death, dece-dents will be counted twice.2 Prescription opioid deaths are drug/poison deaths where one or more prescription opioids caused or contributed to death.3 The number of fatal heroin overdoses in 2014 is estimated based upon data for January 1, 2014 to June 30, 2014.
<1 1-4 5-9 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ <1 1-4 5-9 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84 85+
Fentanyl *
0 0 0 0 1 11 30 26 22 9 0 0 0
Heroin *
0 0 0 0 4 22 76 57 37 13 4 0 0
Opiate Prescription Drugs *
0 0 1 0 2 24 105 80 93 52 14 3 2
Total Drug Deaths +
0 0 0 0 4 22 76 57 37 117 26 5 5
10
30
50
70
90
110
130
10
30
50
70
90
110
130
Total Number of Fentanyl, Heroin, and Opiate Prescription Drugs Causing or Contributing to Death by Age Group, 2013
Num
ber o
f D
rugs D
etected
Num
ber o
f D
eaths
* Deaths due to fentanyl, heroin, and opiate prescription drug overdoses are tallied by the drugs causing or contributing to death. Fatalities involving more than one of these drugs will be represented more than once in the relevant age group.+Total drug deaths represent all fatalities due to drugs and are counted as one occurrence, even though one or more drugs caused or contributed to that death.
FEMALE42.2%
MALE57.8%
Percentage of Fatal Heroin Drug Overdoses by Gender, 2013
FEMALE31.4%
MALE68.6%
Percentage of Fatal Opiate Prescription Drug Overdoses by Gender, 2013
Heroin and Prescription Opiates
Heroin under-represented• Heroin is Morphine Pro-drug• Diagnosis of Heroin COD
• 6-Acetyl Morphine• Circumstances
Opiates – prescription vs. illicit• Medical Records• Scene and circumstances
Heroin3,6 Diacetyl Morphine
6-Acetyl Morphine
Morphine
Inactive Metabolites
T ½2-3 min
T ½< 5 min
T ½2-3 hours
Definition
Half LifeThe length of time it takes the concentration of a drug in the blood to decrease to ½ of its current value
Time
0
20
40
60
80
100
120
T1/2 = 1T1/2 = 2
Heroin
• Diacetyl (3,6) Morphine
• T ½ 2-3 min• Inactive but rapidly
converted to morphine• Liver – glucuronide –
kidney• RUSH occurs while
conversion to 6-MAM and morphine in brain
6-acetyl morphine
Monoacetyl morphine• T ½ less than 5 min• Psychoactive
metabolite, somewhat more potent than morphine
• May be responsible for RUSH
Greater histamine release than morphine when IV
Morphine
• T ½ 2 – 3 hours• Liver – glucuronide
- kidney
Heroin3,6 Diacetyl Morphine
6-Acetyl Morphine
Morphine
Inactive Metabolites
T ½2-3 min
T ½< 5 min
T ½2-3 hours
Heroin
• > 20% average annual increase over decade
• 35% increase from 2011 to 2012
• 58% increase from 2012 to 2013
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
*0
50
100
150
200
250
0 4
19
10089
107
48
100
135
213 210
Number of Fatal Heroin Overdoses2004-2014*
Year
Num
ber
of
Death
s
1 Fatal heroin overdoses may have one or more drug/poisons contributing to death.2 The number of fatal heroin overdoses in 2014 is estimated based upon six months of data for Janu-ary 1, 2014 to June 20, 2014.
Opiates – Prescription vs. illicit
Prescription Opiate Drugs
• 4 % average annual increase over 7 years
• 13% increase from 2012 to 2013
• 9% projected increase from 2013 to 2014
2007 2008 2009 2010 2011 2012 2013 20140
100
200
300
400
500
600
389422
398415
487
414
468
508
Number of Fatal Prescription Opiod Overdoses by Year, 2007-2014*
Year
Num
ber
of
Death
s
1 Heroin and prescription drug deaths are tallied separately. Where heroin and prescription opioids caused or contributed to death, dece-dents will be counted twice.2 Prescription opioid deaths are drug/poison deaths where one or more prescription opioids caused or contributed to death.3 The number of fatal prescription opiod overdoses in 2014 is estimated based upon data for January 1, 2014 to June 30, 2014.
Heroin and Prescription Opioids
Codei
ne
Heroi
n
Hydro
codo
ne
Hydro
mor
phon
e
Fent
anyl
Metha
done
Morph
ine
Oxyco
done
Oxym
orph
one
0
20
40
60
80
100
120
140
160
180
200
11
36
69
40
102 104
85
180
52
Number of Opioid Drugs Causing or Contributing to Death in Fatal Prescription Opioid Overdoses (n=468), 2013
Opioid Drug
Num
ber
of
Dru
gs
1 Prescription opiod deaths may have more than 1 opiod causing or contributing to death2 Morphine is not reported for heroin deaths due to it being a metabolite of heroin
Heroin and Prescription Opiate Drugs
2007 2008 2009 2010 2011 2012 2013 20140
100
200
300
400
500
600
100 89107
48
100
135
213 210
389
422398
415
487
414
468
508
Number of Fatal Heroin and Prescription Opiate Overdoses by Year, 2007-2013
Heroin
Prescription Opiods
Year
Num
ber
of
Death
s
1 Heroin and prescription drug deaths are tallied separately. Where heroin and prescription opioids caused or contributed to death, dece -dents will be counted twice.2 Prescription opioid deaths are drug/poison deaths where one or more prescription opioids caused or contributed to death.3 The number of fatal heroin and prescription opiod overdoses in 2014 is estimated based upon data for January 1, 2014 to June 30, 2014.
From 2007-2013, nearly 70% of all drug/poison deaths were
attributed to opiates.
Surveillance Roles
Situational Awareness• Monitor death incidence as close to real time
as possible.• Forecast and warn public.
Prevention• Identify strategies.• Evaluate and document result of strategy
implementation.
Surveillance Data
OCME Death data delayed by 3 to 6 monthsOther data streams include:
• Hospital and ER admissions – VDH• Law enforcement drug seizures – DFS• Law enforcement intelligence – i.e. Fusion• Prescription Monitoring Program (PMP)
SummaryHeroin under-represented
• Heroin is Morphine Pre-drug• Diagnosis of Heroin COD
• 6-Acetyl Morphine• Circumstances
Opiates – prescription vs. illicit• Medical Records• Scene and circumstances
General increase in deaths from both over the last decade.• Heroin approximately 20% per year, 35% in 2012, >50% in
2013• Prescription opiates approximately 10% per year, 15% in 2012
Surveillance• Situational Awareness• Identify Prevention Strategies• Evaluate Prevention Strategies
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