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Prescription Drug Overdose Mortality Surveillance Review. Len Paulozzi, MD, MPH. Division of Unintentional Injury Prevention National Center for Injury Prevention and Control Centers for Disease Control and Prevention Core VIPP State Training Mtng Pre-Session, April 21, 2013.

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Prescription drug overdose mortality surveillance review
Prescription Drug Overdose Mortality Surveillance Review

Len Paulozzi, MD, MPH

Division of Unintentional Injury Prevention

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

Core VIPP State Training Mtng Pre-Session, April 21, 2013

National Center for Injury Prevention and Control

Division of Unintentional Injury Prevention


Motor vehicle traffic poisoning and drug poisoning overdose death rates us 1980 2010
Motor vehicle traffic, poisoning, and drug poisoning (overdose) death rates,US, 1980-2010

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


Drug overdose deaths by major drug type us 1999 2010
Drug overdose deaths by major drug type, (overdose) death US, 1999-2010

16,651

CDC/NCHS National Vital Statistics System, CDC Wonder.


Outline of presentation
Outline of presentation (overdose) death

  • Death certificate

  • Death certification systems

  • Defining underlying cause

  • Pitfalls with underlying cause

  • Defining multiple causes

  • Pitfalls with multiple causes

  • Guidelines for opioid death certifiers

  • Using CDC WONDER


Death certificate
Death Certificate (overdose) death

  • Information entered by the medical certifier determines the cause of death

  • Text converted to numeric codes largely by computer.


To Be Completed By: (overdose) death

MEDICAL CERTIFIER

X


What is an underlying cause
What is an underlying cause? (overdose) death

  • The single factor that caused death.

  • Not recorded in a certain place on the death certificate.

    • Theoretically the last line in Part I of the cause of death section

  • Derived from the cause of death information in aggregate


Definition of a drug overdose death
Definition of a drug overdose death (overdose) death

  • Death certificate indicates underlying cause of death was “overdose,” “poisoning,” or “intoxication” with a drug

    • The word “drug” sufficient

    • More specific drugs categorized using a standard table.

    • Alcohol and organic solvents not drugs.

    • OTC, rx, and street/illicit drugs included.


Accuracy of death certificate codes for drug overdose deaths
Accuracy of death certificate codes (overdose) death for drug overdose deaths

  • New Mexico study* for 1995-1998

    • Gold standard: state medical examiner files

      • 1,046 poisoning deaths

    • Underlying ICD9 cause codes for death certificates

      • 1,046 poisoning deaths

    • In both: 987 deaths

    • Sensitivity: 94.4% of ME’s total

    • Predictive value positive: 94.4% of death certificate count

  • Differences in definition possible

  • Results possibly different in a coroner system

Landen MG, et al. Am J Epidemiol 2003;157:273-278



Comparability with icd 9
Comparability with ICD-9 (overdose) death

  • Ninth Revision of the ICD (ICD9) coded mortality data from 1979 through 1998.

  • Comparability ratio between ICD9 and ICD10 for poisoning is good: 1.9% more deaths due to poisoning if the same mortality file is coded by ICD10 rather than ICD9.*

  • ICD9 codes for drug poisoning:

    • Unintentional: E850-E858

    • Suicide: E950-E950.5

    • Undetermined: E980-E980.5

    • Homicide: E967.0

* Source: Nat Vit Stat Rep, vol 52, no. 21, June 2, 2004.


Cdc drug poisoning definitions
CDC “Drug Poisoning” Definitions (overdose) death

  • Synonymous with drug overdose or drug intoxication

    • NOT the same as “drug present”

  • Essentially same as “Acute poisoning due to effects of drugs” from ISW 7

  • Does not include the chronic poisoning included in “Acute or chronic poisoning due to the effects of drugs” from ISW7

  • Does not include drug-related disease included in “Drug-induced deaths” concept developed earlier by NCHS.


Death investigation systems
Death Investigation Systems (overdose) death

  • In relation to data quality,

    • coroners, who are elected officials, versus

    • medical examiners, who are physicians qualified by training and appointed.

  • Centralized state medical examiner systems

    • advantageous for surveillance

    • OK, MA, RI, OR, MD, NC, UT among core states with drug overdose priority


WA (overdose) death

ME

MT

ND

MN

VT

OR

NH

MA

ID

WI

NY

SD

WY

MI

RI

PA

IA

NJ

NE

NV

OH

DE

IL

IN

UT

MD

CO

WV

VA

KS

MO

CA

KY

NC

TN

OK

AZ

AR

SC

NM

GA

AL

MS

TX

LA

FL

AK

Centralized State ME Office

County/District-based ME (physician) Offices

HI

County-based mixture of ME and Coroner Offices

County-based coroner Offices

Death investigation systems, 2004

*

*

*

*

*

*

*

*

CT

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

State ME

Sources:

National Institute of Justice, Scientific Working Group on Medical Death Investigation, Death Investigation Systems, 2011

Bureau of Justice Statistics, Census of Medical Examiner and Coroner Offices, 2004


Pitfalls in reporting underlying cause of death
Pitfalls in reporting (overdose) death underlying cause of death

  • Unknown cause (R99 or Pending)

  • Mental and behavioral disorders

  • Intent


Pending certificates
Pending certificates (overdose) death

  • Death certificates with “pending” cause of death section when the mortality file is finalized.

  • About 80% of pending certificates have underlying cause: R99 Other ill-defined and unspecified causes of mortality

    • 4,800 in 2010

  • Drug poisoning deaths

    • Lengthy investigations

    • Initially submitted as pending

    • Over-represented among pending deaths


Annual variation in percent pending c ertificates
Annual variation in percent (overdose) death pending certificates

  • In 2009, about 2% of all certificates pending in OH, WV, NJ and DC

  • Percent pendings higher than normal

    • CA in 2000-2001

    • NY in 1999-2005

    • WV in 2005

    • DC in 2003, 2005, 2007-2008

    • GA in 2008

  • NCHS working hard to reduce pendings


Drug poisoning death rate and percent final non pending certificates california 1999 2009
Drug poisoning death rate and (overdose) death percent final non-pending certificatesCalifornia, 1999-2009

Source: NCHS, data from the National Vital Statistics System


Drug poisoning deaths recorded as unknown cause r99 deaths 15 54 years old california 1999 2006
Drug poisoning deaths recorded as unknown-cause (R99) deaths, 15-54 years old, California, 1999-2006

Unintentional motor vehicle traffic

Unintentional Drug Poisoning


Opioid analgesic overdose deaths and unknown cause r99 deaths west virginia 1999 2010
Opioid analgesic overdose deaths and unknown-cause (R99) deaths, West Virginia, 1999-2010

Opioid overdose


Overdose deaths all ages and unknown cause r99 deaths 15 64 years old ohio 1999 2010
Overdose deaths all ages and unknown-cause (R99) deaths 15-64 years old, Ohio, 1999-2010

Overdose

Source: CDC WONDER


Recommendations on pending deaths
Recommendations on pending deaths 15-64 years old, Ohio, 1999-2010

  • Work with your vital statistics office to encourage timely submission of deaths with a final cause assigned

  • Check your state mortality file for annual changes in percent pending or percent poisoning

  • Check your state mortality for variation in percent pending by county

    • Be cautious in interpretation if variation is noted


Deaths assigned to mental and behavioral disorders
Deaths assigned 15-64 years old, Ohio, 1999-2010to mental and behavioral disorders

  • 1,732 deaths in 2010 attributed to “mental and behavioral disorders” due to drugs

    • Underlying cause F11-F16, and F19

  • 204 deaths in 2010 attributed to “mental and behavioral disorders due to use of opioids.”

    • Underlying cause F11

  • If word such as “abuse” or “misuse” or “addiction” appear on the death certificate cause of death section.

  • Use of this category varies by state.

  • Heavy use underestimates drug overdose rates.


Mortality rate for mental behavioral disorders due to drugs us 2007 2010
Mortality rate for mental/behavioral disorders due to drugs, US, 2007-2010

Map produced by CDC WONDER

Age-adjusted rate per 100,000 for F11-16, F19


Acute intoxication from a mental and behavioral disorder included in some definitions
Acute intoxication from a mental and behavioral disorder included in some definitions

  • ISW7 included [F11 – F16] (.0), and F19.0 in “Acute poisoning due to effects of drugs.”

    • Sounds like “poisoning.”

    • Zero deaths with these underlying causes in the

      national mortality files since 2008


The issue of intent of injury
The issue of intent of injury included in some definitions

  • Dangerous drug use often done among people with mental health problems

  • Poisoning deaths more likely to be difficult to assign to unintentional versus suicide intents

  • The use of “undetermined” intent one way to address this uncertainty

  • Use of undetermined varies by state and by region within state.

    • Interstate or county comparisons best done with all intents combined



Percent of overdose deaths with undetermined intent selected core states 2009 2010
Percent of overdose deaths with undetermined intent, selected core states, 2009-2010

States with centralized medical examiner systems shown in red.


Recommendations on reporting overdose mortality by intent
Recommendations on reporting overdose mortality by intent selected core states, 2009-2010

  • Make death certifiers who are using “undetermined” at rates beyond the norm aware of this fact

  • Use “all intents” combined when possible

  • Be wary of interstate or intercounty comparisons of rates by intent categories.


Defining contributing causes of death
Defining Contributing Causes of Death selected core states, 2009-2010


Drugs as contributing causes
Drugs as contributing causes selected core states, 2009-2010

  • Drugs involved in overdoses found in Part I or II of death certificate

  • NCHS directory of drug names corresponding to specific ICD10 poison codes

  • Drug poison codes in range T36-T50

  • Such deaths can have up to 20 contributing causes

    • Specific drug information from these contributing causes

    • Drugs merely present but not contributing not supposed to be listed.

  • “Record axis” variables used for analyses


Defining illicit and prescription drugs in icd10
Defining illicit and prescription drugs in ICD10 selected core states, 2009-2010


Definitions of opiates and opioids
Definitions of opiates and opioids selected core states, 2009-2010

opioids

semi-synthetics: codeine morphine oxycodone hydrocodone

heroin

opium

synthetics: methadone, fentanyl, tramadol

pharmaceutical

opioids

opiates


Distinguishing opioids and opiates in mortality
Distinguishing “opioids” and “opiates” in mortality selected core states, 2009-2010

  • Opioid analgesics and heroin both in 965.0 in ICD9

  • Opioid analgesic poisoning not important enough to assign special code when ICD9 developed.

  • Thus opioid analgesic deaths not countable prior to 1999

  • Why all mortality trends for opioids start at 1999


Pitfalls in reporting contributing causes of death from overdose
Pitfalls in reporting contributing causes of death from overdose

  • Causes of undercounting specific drugs

  • Causes of overcounting specific drugs

  • Assigning responsibility among multiple drugs


Lack of drug specification
Lack of drug specification overdose

  • Drugs not well specified

    • “drug overdose” not otherwise described

    • “multiple drug intoxication”

  • Roughly 25% of all drug overdose deaths NO drugs specified.

  • Percent varies by state (and possibly county).

  • Some ICD10 T codes not specific for illicit versus rx drugs, eg, T43.6, (psychostimulants)


Percent of overdose deaths with 1 drug specified core states 2008 2010
Percent of overdose deaths with 1+ drug specified, core states, 2008-2010

States with centralized medical examiner systems shown in red.

Source: Unpublished analysis by Margaret Warner of NCHS


Percent of overdose deaths with 1+ drug specified against mortality rates by state by type of overdose, 2008-2010


Opioid overdose deaths coded only as drug overdoses with drugs unspecified
Opioid overdose deaths coded only as mortality rates by state “drug overdoses” with drugs unspecified

  • Adjusting each state total by the percent unspecified

  • Result: estimated 22,229 opioid analgesic deaths in 2010

  • 5,578 more than the official count.


Some opioid related deaths not included in opioid overdose totals
Some opioid-related deaths NOT included mortality rates by state in opioid overdose totals

  • Opioids lost if coded to T40.6 (other/unspec narcotics)

    • (2,039 such deaths w/o opioid codes in 2010)

    • Use for opioid analgesics might vary by state

  • Deaths due to the acetaminophen component of opioid-acetaminophen combinations, eg, Vicodin

  • Other injury deaths where opioid sedation might have contributed to death, e.g., motor vehicle crash deaths


The true number of opioid analgesic overdose deaths us 2010
The “true number” of opioid analgesic overdose deaths, US, 2010

16,651 recorded as such

+ some of 488 listed as mental disorders

+ some of 2,039 attributed to “unspecified narcotic”

+ estimated 5,578 where drug not specified

+ some of 4,800 assigned to “unknown cause”

---------------------------------------------------------------

= Way more than 16,651


Possible contributors to over counts of opioid analgesic overdose deaths
Possible contributors to US, 2010over-counts of opioid analgesic overdose deaths

  • Opioids produced by clandestine laboratories sold as illicit drugs

    • Roughly 1,000 opioid overdose deaths in 2006 from fentanyl*

    • Occurs episodically and rarely produces so many deaths.

  • Some heroin overdoses recorded as due to morphine, its metabolite.

  • Opioids implicated when other drugs involved were causative

    • Most overdose deaths involve multiple drugs

    • Opioids most commonly paired with benzodiazepines, which infrequently cause death by themselves.

*See Jones. S et al. MMWR 2008;57:793-796


Multiple drugs contributing to an overdose death
Multiple drugs contributing US, 2010to an overdose death

  • Partitioning responsibility not possible

  • Deaths counted more than once

  • States vary in number of drugs coded per death


Percentage of overdose deaths for specific psychotherapeutic and CNS pharmaceuticals that involved only a single drug class, US, 2010

Jones CM, et al. Pharmaceutical overdose deaths, United States, 2010; JAMA 2013;309(7):657-659.


Recommendations for reporting drugs as contributing causes of overdose death
Recommendations for reporting drugs as contributing causes of overdose death

  • Note possible causes of undercounts and overcounts in limitations

  • Cautious of annual changes by specific drug due to changes in specificity

  • Geographic comparisons of rates for drugs risky

  • Note that drugs sum to more than total

  • Be clear that drugs “caused” deaths and were not just “present.”


Using cdc wonder
Using CDC WONDER of overdose death

  • See CDC Users Guide for access instructions

  • Data usually two years out of date

  • Multiple “by” variables available

  • State and county specific

  • Age-adjustment, mapping and chart construction

  • Contributing drugs available in WONDER Multiple Cause of Death Data

  • Numbers might differ from state files

  • Drug poisoning deaths cannot be identified in NCIPC WISQARS.

http://wonder.cdc.gov/

http://wonder.cdc.gov/mcd.html


Recommendations for the investigation diagnosis and certification of deaths related to opioid drugs
“Recommendations of overdose deathfor the Investigation, Diagnosis, and Certification of Deaths Related to Opioid Drugs”

  • National Association of Medical Examiners and American College of Medical Toxicology recommendations

  • Includes scene investigation and drug testing guidelines

  • Useful to distribute to your coroners and/or medical examiners

Davis et al, AcadForen Path 2013; 3(1): 62-76 and 77-83.


Additional information
Additional Information of overdose death

http://www.cdc.gov/HomeandRecreationalSafety/pdf/PolicyImpact-PrescriptionPainkillerOD.pdf

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6126a5.htm?s_cid=mm6126a5_w


Acknowledgement: Thanks to Dr. Margaret Warner of NCHS for allowing use of some of her slides.

Len Paulozzi, MD, MPH

[email protected]

The findings and conclusions in this report are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention/the Agency for Toxic Substances and Disease Registry.


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