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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
10Data Source: WV Health Statistics Center, Vital Statistics System* - 2012 and 2013 Preliminary
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
12Data Source: WV Health Statistics Center, Vital Statistics System
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
13Data Source: WV Health Statistics Center, Vital Statistics System* - 2012 and 2013 Preliminary
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)
2001-2013 Occurrences by Year
Alprazolam Diazepam Gabapentin
Citalopram AmitriptylineDeaths
15
Data Source: WV Health Statistics Center, Vital Statistics System* - 2012 and 2013 Preliminary
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
2001-2013 Occurrences by Year
AlprazolamOxycodoneDiazepamHydrocodoneD
eaths
16
Data Source: WV Health Statistics Center, Vital Statistics System* - 2012 and 2013 Preliminary
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-)
2001-2013 Occurrences by Year
Heroin Cocaine
Amphetamine (inc. Meth)Deaths
17
Data Source: WV Health Statistics Center, Vital Statistics System* - 2012 and 2013 Preliminary
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
2001-2013 Occurrences by Year
Heroin Oxycodone Hydrocodone
Deaths
18
Data Source: WV Health Statistics Center, Vital Statistics System* - 2012 and 2013 Preliminary
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
Data Source: WV Health Statistics Center, Vital Statistics System* - 2012 and 2013 Preliminary
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
20Data Source: WV Health Statistics Center, Vital Statistics System
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
All (inc. suicides and homicides) Accident Undetermined
Deaths
21Data Source: WV Health Statistics Center, Vital Statistics System
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
22Data Source: WV Health Statistics Center, Vital Statistics System
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
23Data Source: WV Health Statistics Center, Vital Statistics System
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
All (inc. suicides and homicides) Accident Undetermined
Deaths
24Data Source: WV Health Statistics Center, Vital Statistics System
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
All (inc. suicides and homicides)AccidentUndetermined
Deaths
25Data Source: WV Health Statistics Center, Vital Statistics System
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
All (inc. suicides and homicides)AccidentUndetermined
Deaths
26Data Source: WV Health Statistics Center, Vital Statistics System
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
All (inc. suicides and homicides)AccidentUndetermined
Deaths
27Data Source: WV Health Statistics Center, Vital Statistics System
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
28Data Source: WV Health Statistics Center, Vital Statistics System
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
All (inc. suicides and homicides)AccidentUndetermined
Deaths
29Data Source: WV Health Statistics Center, Vital Statistics System
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
All (inc. suicides and homicides) Accident Undetermined
Deaths
30Data Source: WV Health Statistics Center, Vital Statistics System
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
All (inc. suicides and homicides)AccidentUndetermined
Deaths
31Data Source: WV Health Statistics Center, Vital Statistics System
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
All (inc. suicides and homicides) Accident Undetermined
Deaths
32Data Source: WV Health Statistics Center, Vital Statistics System
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
All (inc. suicides and homicides)AccidentUndetermined
Deaths
33Data Source: WV Health Statistics Center, Vital Statistics System
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.
42