Unintentional Poisonings - North Carolina Public Health Association

Report
Prescription Drug Overdose
In North Carolina
State Health Director’s Meeting
Jan 24th, 2014
Agenda
• Overview & Surveillance
– Dr. Steve Marshall, UNC Injury Prevention Research
Center (IPRC)
• Legislative Changes (S222 & S20)
– Elizabeth Hudgins, Child Fatality Task Force (CFTF)
• Project Lazarus/CCNC-Community
Prevention
– Dr. Robin Cummings, State Health Director
Problem Overview
• Epidemiology of the Overdose Problem
• Personal Stories
• What is NC doing?
– Response Coordination
– Local ED Surveillance of Overdose
– CSRS
– Research at UNC IPRC
Disclosures
• No financial interests or disclosures
• My partner, Dr. Anna Waller, is associated
with the NC-Detect system, which I will be
speaking about today
Definition – Prescription Drug Overdose
• What is a prescription drug overdose?
– Acute poisoning by prescription medication
– Opioids or “narcotics” (e.g. hydrocodone, oxycodone,
oxymorphone, methadone)
– Benzodiazepines
– Any other prescription medication
• Any substance can become a poison
- Dose makes the poison, not the substance
Problem Overview:
US Prescription Overdose
Pain Management by Medication
• Positives
– Prescription painkillers
help people manage
chronic pain, greatly
improve quality of life
• Negatives
– Patient addiction &
dependence
– Diversion of drugs for
illicit purposes
– Overdose
15,000 prescription painkiller overdose
deaths annually in US
1 in 20 people (>12 yrs) used
prescription pain killers for
“nonmedical purposes”
Enough prescription painkillers were
prescribed annually to medicate every
US adult around-the-clock for a month
November 2011
North Carolina Poisonings Data
2000
Unintentional Poisoning and Motor Vehicle Deaths
North Carolina Residents, 1999–2012
1800
Motor Vehicle/Transportation
1600
1400
1200
1000
800
Poisoning
600
400
200
0
1999
11
2000
2001
2002
2003
2004
2005
2006
National Vital Statistics System, http://wonder.cdc.gov, multiple cause dataset
Source: Death files 1999-2012, State Center for
Health Statistics. Analysis by Injury Epidemiology
and Surveillance Unit
2007
2008
2009
2010
2011
2012
Unintentional Poisoning Deaths
by Drug Type and Year: N.C. Residents, 1999-2012
800
Opioid Pain Medications
700
Cocaine
600
Heroin
500
400
300
200
100
0
1999
2000
2001
2002
2003
2004
Note: categories are not mutually exclusive
Source: N.C. State Center for Health Statistics, Vital StatisticsDeaths, 1999-2012 (2012 Provisional)
Analysis by Injury Epidemiology and Surveillance Unit
2005
2006
2007
2008
2009
2010
2011
2012
Unintentional Poisoning Deaths, 1999-2001
Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 1999-2012
Analysis by Injury Epidemiology and Surveillance Unit
Unintentional Poisoning Deaths, 2002-2005
Source: N.C. State Center for Health Statistics,
Vital Statistics-Deaths, 1999-2012
Analysis by Injury Epidemiology and
Surveillance Unit
Unintentional Poisoning Deaths, 2006-2009
Source: N.C. State Center for Health Statistics,
Vital Statistics-Deaths, 1999-2012
Analysis by Injury Epidemiology and
Surveillance Unit
Unintentional Poisoning Deaths, 2010-2012
Source: N.C. State Center for Health Statistics,
Vital Statistics-Deaths, 1999-2012
Analysis by Injury Epidemiology and
Surveillance Unit
Personal Stories:
The Polarizing Effect of Drug Abuse
Deadly Pills: A National Epidemic
Kristen Mascia, People Magazine 01/28/2013
Photo: New York Daily News
• Joey DiBernardo Jr, 40 yr old NY firefighter
• Age 36 yrs: severe occupational injuries
jumping from a burning building
• Cycle of chronic pain, depression, and
dependence on prescribed painkillers
• Expressed deep concern about
dependence on medicines
• Fatal overdose: combined opioid
hydromorphone with antidepressant
citalopram
• Not a recreational drug abuser, simply
someone trying to live through pain
• Needed access to information on dangers
of combining medicines
Deadly Pills: A National Epidemic
Kristen Mascia, People Magazine 01/28/2013
• Harry Cohen, 17 yr old QB, Burlington, NC
• Took methadone prescribed for a family
member with fibromyalgia
• No reported prior history of drug abuse
• Classic novice experimenting with drugs
• Probably limited comprehension of
interaction of dosage, tolerance, and body
weight
Photo: http://www.harryecohen.com/
Deadly Pills: A National Epidemic
Kristen Mascia, People Magazine 01/28/2013
“Jace Flom's mom died two weeks after her birth
of an overdose of prescription drugs”
Photo: Grant Delin
Deadly Pills: A National Epidemic
Kristen Mascia, People Magazine 01/28/2013
•
•
•
•
Melanie Flom, 26 yr old mother
Chronic pain from car crash injuries at age 20
Transitioned to a routine recreational drug abuser
Fatal overdose event: Combined her prescribed
painkillers with other prescription painkillers given
to her by friends, plus alcohol
Photo: Grant Delin
Online comments discuss the perception of addiction as
a failure of character, rather than a treatable disorder:
• “This child is better off without her druggie mom”
• “Addiction is a choice, not a disease”
• “Addiction IS a disease, but getting help is a choice”
Context for Public Health Prevention Efforts:
Concerns from Pain Patients about Access to Medicine
“Articles like this make it harder and harder to
get the medication we need to just have a seminormal day. I, for one, do NOT abuse what is
given me.”
Photo: Grant Delin
Online Comments from Readers on
Deadly Pills: A National Epidemic
People Magazine 01/28/2013
“Please don't judge those of us who rely on
these medications and take them the way they
are prescribed …. I have never felt high or
impaired on my medication.”
“I'm now 34yrs old and have had 6 MAJOR
surgeries relating to different diagnoses,
starting at the age of 13, I can tell you that
without a doubt, I would NOT be able to
function, at even a semi-normal level, without a
prescription for a strong narcotic.”
North Carolina’s Response:
Coordinating between Partners
North Carolina Injury and Violence Prevention Branch
Epidemiology, Policy, Partners, Community
North Carolina
Comprehensive Community Approach
Chronic Pain Initiative
Opioid Death Task Force
Policy
Prescription
Drug
Monitoring
System
Poisoning Death Study
Substance
Abuse
SAC Poisoning
Workgroup
Policy & Practice
Research
Enforcement
Drug Take Back
SBI & Medical Board
Div. of Public Health
Div. Medical Assistance
Div. Mental Health/Substance Abuse
North Carolina’s Response:
Take Back Events
Supply and Need
• Expected duration of pain may be
short-term
– EG: 2-5 days following surgery
• Dispensed quantity is often longer
– EG: 30 days
• Natural reluctance to throw it away,
in case you “need it some day”
• Result: Gradual accumulation of
dangerous medicines in homes
Safe Kids and
Operation
Medicine Drop
facilitate safe
disposal of
medicines in NC
Searchable index of community drop-off
locations & community take-back events
North Carolina’s Response:
Realtime ED Surveillance of Drug
Overdose in Your County
Deaths vs. ED visits for drug overdose, NC 2011
1,222 deaths
22,992 ED visits
The number of ED visits for
overdose dwarfs the
number of overdose deaths
Average NC county has about one
overdose death per month but just
under one overdose ED visit per day
© 2014 University of North Carolina at Chapel
Hill and NC Division of Public Health, NC DHHS
Unintentional Poisoning ED Visits, 2011
Source: Division of Public Health, NC DETECT-ED visit data, 2011
Analysis by Injury Epidemiology and Surveillance Unit
NC DETECT coding for substance abuse, Dx and E-codes as primary
Local ED surveillance data using NC DETECT
 NC DETECT was created in 2004 to address the need for timely
detection of public health emergencies.
 In 2005, under NC General Statute § 130A-480, all 24/7, acutecare, hospital-affiliated EDs were required to submit ED visit data
every 12 hours.
 In addition to ED visit data, NC DETECT captures data from the
Carolinas Poison Center (CPC), the Pre-hospital Medical
Information System (PreMIS), four VA Medical Center EDs, and
select urgent care centers.
© 2014 University of North Carolina at Chapel
Hill and NC Division of Public Health, NC DHHS
NC DETECT Overdose
Surveillance
• 4 reports currently available on Hot Topics
Dashboard & Custom Event Line Listing
• 9 additional to be added soon
• Graphs, line listing information available
– ZIP code maps for select reports by June
© 2014 University of North Carolina at Chapel
Hill and NC Division of Public Health, NC DHHS
Dashboard of Overdose Reports
For Your County
© 2014 University of North Carolina at Chapel
Hill and NC Division of Public Health, NC DHHS
Opioid OD Graph from NC DETECT
© 2014 University of North Carolina at Chapel
Hill and NC Division of Public Health, NC DHHS
© 2014 University of North Carolina at Chapel Hill and NC Division of Public Health, NC DHHS
Report on Opioid Analgesic Overdose
ED Visits for Your County
Age
Sex Chief
Group
Complaint
Triage Note
XX
XX
Overdose
Chief Complaint Subjective: Per EMS, wife last
saw normal, woke up and found him on the
couch with agonal breathing. When EMS arrive,
gave Narcan. Patient awake and cooperative at
this time.
XX
XX
DRUG
OVERDOSE
denies suicide, crushed and injected XXX
XX
XX
XX
XX
DRUG
OVERDOSE
OVERDOSE
© 2014 University of North Carolina at Chapel
Hill and NC Division of Public Health, NC DHHS
pt states took 5 XXXX around XX. pt appears
sleepy. pt A+O x4. pt denies SI states she was
hurting in neck and back. EMS states ….
per ems pt from home poss od on ambien, xanax
and neurontin, ems sts blood sugar on scene,
ems sts pt was last found normal approx XXX
© 2014 University of North Carolina at Chapel Hill and NC Division of Public Health, NC DHHS
http://www.ncdetect.org/
Account
Request
© 2014 University of North Carolina at Chapel
Hill and NC Division of Public Health, NC DHHS
NC DETECT Training
• Contact Jenna Waggoner or Amy Ising for
customized Web-based or in-person
training
– [email protected][email protected] (919) 966-8853
• NC DETECT User Guide available online
• Help icon on dashboard reports
© 2014 University of North Carolina at Chapel
Hill and NC Division of Public Health, NC DHHS
NC Controlled Substance
Reporting System (CSRS)
Controlled Substance Reporting System
• Allows a healthcare provider to review complete
prescription history for a patient
– Including prescriptions from other providers
• Excellent idea, but not used by all providers
– Legislative committees to study the CSRS
– Legislative bills to strengthen the CSRS
– Invaluable information for public health monitoring
and analysis of provider prescribing
Source: Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on Drug Use and Health:
Summary of National Findings. Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies; 2013.
UNC IPRC
Overdose Research
UNC IPRC Research
• Funding:
– CDC, NIJ, Kate B. Reynolds Foundation
• Research Topics include Evaluating:
– ED protocols for managing pain patients
– Effectiveness of the CSRS in NC and similar
programs nationally
– Project Lazarus and Chronic Pain Initiative
– Surveillance Methodologies
– Identification of Select Health Care Providers
– Medicaid’s Lock-In Program
Acknowledgements
•
IVPB / DPH:
• Scott Proescholdbell
•
NC-Detect / DPH:
• Katie Harmon, Amy Ising, Lana Deyneka,
many others
•
UNC:
• Chris Ringwalt, Mariana Garrettson,
Nabarun Dasgupta
•
Others:
• Fred Brason, Kay Sanford
Thank you!
Steve Marshall, PhD
Injury Research Prevention Center (IPRC)
& Gillings School of Global Public Health
University of North Carolina-Chapel Hill
[email protected]
injuryfreenc.org
iprc.unc.edu

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