Surveillance of Drug Use and Overdose – An Overview

2013 CSTE Preconference Workshop

Brad WhortonJim Davis

Michael LandenNew Mexico Department of Health

Categories of Indicators

• Overdose death• Overdose hospitalization– Neonatal abstinence syndrome

• Overdose emergency department visits• Prescription opioid sales• Controlled substance prescribing• Drug use prevalence

Overdose Death

Heroin Total Drug Overdose0.0

5.0

10.0

15.0

20.0

25.0

30.0

3.4

25.9

Total Drug Overdose and Heroin Overdose Death RatesNew Mexico, 2011

Age-

adju

sted

dea

th ra

te p

er 1

00,0

00 p

erso

ns

Rates are age-adjusted per 100,000 to the standard 2000 U.S. population Source: Bureau of Vital Records and Health Statistics, New Mexico Department of Health

Methods• Used NM vital records multiple cause of death data.

• New Mexico resident deaths. •Total drug overdose death• underlying cause of death code (X40-X44, X60-X64, X85,

Y10-Y14).

• Heroin overdose death• any multiple cause of death field was equal to T40.1 • AND the underlying cause of death code was defined as a

total drug overdose death (X40-X44, X60-X64, X85, Y10-Y14).

• Rates were age-adjusted to the 2000 standard U.S. population.

Rates are age-adjusted per 100,000 to the standard 2000 U.S. population Source: Bureau of Vital Records and Health Statistics, New Mexico Department of Health

Rx Opioid Total Drug Overdose0.0

5.0

10.0

15.0

20.0

25.0

30.0

8.0

25.9

Prescription Opioid Overdose and Total Drug Overdose Death Rates, New Mexico, 2011

Age-

adju

sted

dea

th ra

te p

er 1

00,0

00 p

erso

ns

Methods• Used NM vital records multiple cause of death data.

• New Mexico resident deaths. • Prescription Opioid overdose death• any multiple cause of death field was equal to T40.2 to T40.4• AND the underlying cause of death code was defined as a drug

overdose death (X40-X44, X60-X64, X85, Y10-Y14).

• This definition is based on methods from “Vital Signs: Overdoses of prescription opioid pain relievers—United States, 1999-2008,” MMWR, Nov 4, 2011, 60(43):1487-1492.

• Rates were age-adjusted to the 2000 standard U.S. population.

Issue Prescription opium (T40.0) and Other and unspecified narcotics (T40.6) are excluded from the definition.

Sedative-Hypnotics Total Drug Overdose0.0

5.0

10.0

15.0

20.0

25.0

30.0

2.8

25.9

Sedative-Hypnotic Overdose and Total Drug Overdose Death Rates, New Mexico Residents, 2011

Age-

adju

sted

dea

th ra

te p

er 1

00,0

00 p

erso

ns

Rates are age-adjusted per 100,000 to the standard 2000 U.S. population Source: Bureau of Vital Records and Health Statistics, New Mexico Department of Health

Methods Used NM vital records multiple cause of death data.

New Mexico resident deaths. Sedative-Hypnotic overdose death

any multiple cause of death field was equal to T42.3, T42.4, T42.6, or T42.7

AND the underlying cause of death code was defined as a total drug overdose death (X40-X44, X60-X64, X85, Y10-Y14).

Rates were age-adjusted to the 2000 standard U.S. population.

Issue Rate may also include deaths due to other and unspecified antiepileptic drugs.

Unspecified Total Drug Overdose0.0

5.0

10.0

15.0

20.0

25.0

30.0

10.2

25.9

Unspecified Drug Overdose and Total Drug Overdose Death Rates, New Mexico Residents, 2011

Rates are age-adjusted per 100,000 to the standard 2000 U.S. population Source: Bureau of Vital Records and Health Statistics, New Mexico Department of Health

Methods• Used NM vital records multiple cause of death data.

• New Mexico resident deaths. • Unspecified overdose death• any multiple cause of death field was equal to T50.9 and there

were not any multiple cause fields with values between T36 and T50.8• AND the underlying cause of death code was defined as a total

drug overdose death (X40-X44, X60-X64, X85, Y10-Y14).

• Rates were age-adjusted to the 2000 standard U.S. population.

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 20110.0

5.0

10.0

15.0

20.0

25.0

Heroin, Prescription Opioids, Prescription Sedatives, Unspecified, and Total Unintentional Drug Overdose Death Rates, New Mexico, 1990-2011

HeroinRx OpioidRx SedativesUnspecifiedTotal

Age-

adju

sted

per

100

,000

per

sons

Source: New Mexico Office of the Medical Investigator

Issues• Rates calculated using vital records data may differ from those based on medical investigator data due to:• different coding systems.• different jurisdictions/populations (Medical Investigator

data may not include out-of-state resident deaths or toxicology/autopsy results of deaths on tribal or federal lands).

• The greater the unspecified category, the more difficult it is to assess specific drug overdose death rates. • Changes with changes of death certifiers• Changes with changes to toxicology panels

Overdose Hospitalization

2009 2010 20110.0

2.0

4.0

6.0

8.0

10.0

12.0

9.2

11.110.2

Drug Overdose Hospital Inpatient Discharge Rate New Mexico, 2011

Age-

adju

sted

rate

per

10,

000

pers

ons

Data include hospital discharges primary diagnosis) from in-state, non-federal hospitals (IHS not included). SOURCE: New Mexico Department of Health, Hospital Inpatient Discharge Data

Methods• Used the primary diagnosis for drug overdose (ICD-9 codes E850-E858, E950-E950.5, E962, E980-E980.5) in the state’s Hospital Inpatient Discharge Database (HIDD).

• New Mexico resident hospitalizations.

• Rates were age-adjusted to the 2000 standard U.S. population.

• HIDD only contains discharges from non-federal hospitals. Indian Health Service (IHS) and Veterans Administration (VA) facilities are not included in the data.

• HIDD does not contain hospital discharges to New Mexico residents discharged from out of state hospitals.

• Overdoses that result in only an ED visit without a hospital admission are not included in the HIDD.

• Admission criteria may differ among hospitals.

Issues

Neonatal Abstinence Syndrome

Data include hospital discharges (all diagnoses) from in-state, non-federal hospitals (IHS not included) SOURCE: New Mexico Department of Health, Hospital Inpatient Discharge Data and Vital Records data

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 20110.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

1.72.1

1.51.7 1.9

1.61.9

2.3

3.33.8

4.4

6.2

Neonatal Abstinence Syndrome New Mexico, 2000-2011

Rate per 1,000 Live Births

Methods• Used all diagnoses for neonatal abstinence syndrome (ICD-9 code 779.5) for New Mexico residents in the state’s Hospital Inpatient Discharge Database (HIDD) for the numerator.

• Used NM vital records to generate the number of live births to New Mexico residents for the denominator.

• Calculated the rate per 1,000 live births.

Issues

• HIDD only contains discharges from non-federal hospitals. Indian Health Service (IHS) and Veterans Administration (VA) facilities are not included in the data which may result in an undercount.

• HIDD does not contain hospital discharges to New Mexico residents discharged from out of state hospitals.

• The diagnosis of neonatal abstinence syndrome will vary by hospital and physician.

Overdose Emergency Department Visits

Methods• Used the primary diagnosis for drug overdose (ICD-9 codes E850-E858, E950-E950.5, E962, E980-E980.5) in the state’s Emergency Department Database.

• New Mexico resident emergency department visits.

• Rates were age-adjusted to the 2000 standard U.S. population.

• Only includes emergency department visits from non-federal hospitals. Indian Health Service (IHS) and Veterans Administration (VA) facilities are not included in the data.

• Emergency department visits among New Mexico residents discharged from out of state emergency departments are not included.

• E-coding can vary by hospital.

Issues

Prescription Opioid Sales

2010 20110.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

10.0

5.5 5.8

Prescription Opioid Sales Ratio, New Mexico, 2010-2011kg

per

10,

000

popu

latio

n

Sales ratios were calculated based on sales by weight (kilogram) per 10,000 population Source: ARCOS (Automation of Reports and Consolidated order Systems) database, Drug Enforcement Administration

Methods• Used ARCOS DEA data to generate sales by weight (in grams) for prescription opioids in the database.

• Grams by weight was converted to kilograms then divided by the state population per 10,000 persons.

• Calculation and presentation of sales ratios based on methodology from “Vital Signs: Overdoses of prescription opioid pain relievers—United States, 1999-2008,” MMWR, Nov 4, 2011, 60(43):1487-1492.

Issues• ARCOS sales data are provided for individual drugs by weight (in grams). Prescription opioids must be sorted out and summed. Schedule II and Schedule III opioids included in the database.

• Sub-state data are limited to three-digit zip codes. U.S. Census population estimates for zip codes are only generated for decennial census years.

• Sales comparisons between individual opioids may be problematic as some opioids (e.g., Methadone) are not easily converted to MMEs (Morphine milligram equivalents) without specific dosage information, which is not known.

Controlled Substance Prescribing

Opioids Dispensed

Aug-06

Dec-06

Apr-07

Aug-07

Dec-07

Apr-08

Aug-08

Dec-08

Apr-09

Aug-09

Dec-09

Apr-10

Aug-10

Dec-10

Apr-11

Aug-11

Dec-11

Apr-12

Aug-12

0

50,000,000

100,000,000

150,000,000

200,000,000

Total Opioids Dispensed (MME) New Mexico, August 2006-August 2012

Month

Tota

l MM

E (M

orph

ine

equi

vale

nt)

Source: New Mexico Board of Pharmacy, Pharmacy Monitoring Program, 2012

Sedative-Hypnotics Dispensed

Aug-06

Dec-06

Apr-07

Aug-07

Dec-07

Apr-08

Aug-08

Dec-08

Apr-09

Aug-09

Dec-09

Apr-10

Aug-10

Dec-10

Apr-11

Aug-11

Dec-11

Apr-12

Aug-12

0

10,000,000

20,000,000

30,000,000

40,000,000

50,000,000

60,000,000

Total Sedative-Hypnotics Dispensed (VME)New Mexico, August 2006-August 2012

Month

Tota

l VM

E (v

aliu

m e

quiv

alen

t)

Source: New Mexico Board of Pharmacy, Pharmacy Monitoring Program

Definitions• Opioids – All opioid drugs, including morphine, methadone,

fentanyl, buprenorphine, etc.

• Sedative-Hypnotics – Benzodiazepines (e.g. Valium) and Benzo-like sleep aids (e.g. Ambien)

• MME – Morphine milligram equivalents derived from an equivalence factor

• VME – Valium milligram equivalents derived from an equivalence factor

Methods

1. Create translations from National Drug Code (NDC) to drug class, strength and morphine/valium equivalents (resources are available).

2. Apply the conversion factors to the relevant time period of prescription data:

MME = MME_Factor(NDC)*strength(NDC)*quantity

3. Aggregate by year and month.

Issues• Access to PMP data • Statutes and regulations• Technical issues (location, updates, security)

• PMP is a large, complex database• Critical tables are: prescription, practitioner,

patient, pharmacy and drug (NDC).• Requires some processing to make datasets

suitable for analysis.

Dangerous Prescribing Criteria

No cri-teria met (97%)

Duo 32.7%

Trio 30.9%

Multiple 3.6%

High Dose 32.7%

Source: New Mexico Board of Pharmacy, Pharmacy Monitoring Program

Definitions• Prescriber criteria based on prescriptions filled by patients

over 12 months. Minimum of 10 patients and 100 fills per prescriber.

• Duo – At least 50% of patient-months with opioid fills also had benzodiazepine fills.

• Trio – at least 40 patient-months with fills for opioids, benzodiazepines and carisoprodol.

• High dose – at least 20% of opioid prescriptions filled were over 200 MME/day.

• Multiple – more than one of the above.

Methods

• Aggregation in 3 steps:• Prescriber, patient & calendar month• Prescriber, patient (counting months by category)• Prescriber (counting patient-months)

• Patient defined in terms of name and DOB.

Suboxone PrescribingNew Mexico, 2011-2012

MetroNortheast

NorthwestSoutheast

Southwest

0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0

Suboxone patients per 100,000 population

Patients per 100,000 population

Regi

on

MetroNortheast

NorthwestSoutheast

Southwest

0.0 50.0 100.0 150.0 200.0 250.0 300.0 350.0

Suboxone prescribers per 100,000 population

Prescribers per 100,000 population

Regi

on

Methods• Suboxone patient – a patient who has filled 2 or more

prescriptions for suboxone; individual defined by name & dob.

• Suboxone prescriber – a prescriber who has prescribed suboxone to 15 or more patients; duplicate prescriber records combined.

• Region – NM health region as determined by the zip code of the patient or prescriber.

• Data for July 2011 – June 2012.

Issues• Suboxone is used to treat pain in addition to its use in

addiction treatment – not a pure measure of addiction services.

• Zip code to county works fairly well in NM; it may not in other states.

• Suboxone prescribers are more likely to have multiple records in the practitioner file, requiring combining the records to avoid over-counting.

Drug Use Prevalence

* State added questionSource: New Mexico Youth Risk and Resiliency Survey, New Mexico Department of Health

Marij

uana

Cocaine

Inhalants

Heroin

Meth

amphetamine

Ecstacy

Painkiller u

se to

get high*

0.0

5.0

10.0

15.0

20.0

25.0

30.0 27.6

5.26.7

3.2 3.96.4

11.3

Current Prevalence of Drug Use by High School Students Grades 9-12 New Mexico, 2011

Perc

ent o

f stu

dent

s rep

orte

d us

e of

subs

tanc

e in

pas

t 30

days

Cocaine

Heroin

Meth

amphetamine

Ecstacy

Prescr

iption drug w

/o a pre

scription

Lifetime in

jection dru

g use0.0

5.0

10.0

15.0

20.0

25.0

11.4

4.7 5.5

12.2

20.2

3.8

Lifetime Prevalence of Drug Use by High School Students Grades 9-12 New Mexico, 2011

Perc

ent o

f stu

dent

s who

repo

rted

hav

ing

ever

use

d su

bsta

nce

Source: New Mexico Youth Risk and Resiliency Survey, New Mexico Department of Health

Methods• The NM Youth Risk and Resiliency Survey (YRRS) is a survey measuring the prevalence of risk behaviors and resiliency (protective) factors among public high school (grades 9–12) and middle school (grades 6-8) students.

•The YRRS is a part of the Youth Risk Behavior Surveillance System (YRBS), designed and implemented nationally by CDC, and implemented in most states by state Health and/or Education agencies.

• The YRRS is administered anonymously with a paper and pencil survey instrument, in the classroom. Sample size = 5,875.

• Example of a current prevalence question: “During the past 30 days, how many times have you used heroin (also called smack, junk, or China White)?”

• Example of a lifetime prevalence question: “During your life, how many times have you used any form of cocaine, including powder, crack, or freebase?”

Issues• 80 of New Mexico’s 89 public school districts participated in the YRRS in 2011.

• The 2011 high school response rate was 63%.

• Only New Mexico public school students were surveyed. Private schools and Bureau of Indian Education (BIE) schools were not included in the sampling frame.

• Due to methodological differences, particularly in the mode of survey, YRRS prevalence rates may differ from those of other surveys (e.g., NSDUH).

12+ 12-17 18-25 26+0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

2.01.4

6.0

1.4

3.9

5.3

8.2

2.9

Current Prevalence of Drug Use by Age GroupNew Mexico, 2010-2011

Cocaine

Illicit drug use other than marijuana

Perc

ent r

epor

t usin

g su

bsta

nce

durin

g th

e pa

st 3

0 da

ys

Source: National Survey of Drug Use and Health, Substance Abuse and Mental Health Services Administration, 2012

U.S. N.M.0.0

1.0

2.0

3.0

4.0

5.0

6.0

4.4

5.1

Past Year Prevalence of the Non-medical Use of Pain Relievers, Ages 18 and Older, New Mexico and United States, 2010-2011

Perc

ent r

epor

t usin

g su

bsta

nce

durin

g th

e pa

st y

ear

Source: National Survey of Drug Use and Health, Substance Abuse and Mental Health Services Administration, 2012

Methods• The NSDUH is an annual survey of the civilian, non-institutionalized population aged 12 years and older.

• In 2010-2011, NSDUH collected data from 137,913 respondents.

•The national sample was interviewed using a computer-assisted interviewing (CAI) method. The survey used a combination of computer-assisted personal interviewing (CAPI) conducted by an interviewer and audio computer-assisted self-interviewing (ACASI). Use of ACASI is designed to provide the respondent with a highly private and confidential means of responding to questions and increases the level of honest reporting of illicit drug use and other sensitive behaviors.

•2011 NSDUH employed a 50-State design with an independent, multistage area probability sample for each of the 50 States and the District of Columbia.

• The screening response rate (SRR) for 2010-2011 combined averaged 87.7 percent, and the interview response rate (IRR) averaged 74.5 percent, for an overall response rate (ORR) of 65.3 percent.

• Due to methodological differences, particularly in mode of survey, results can differ compared with similar indicators in the YRRS.

Issues

Recommendations

• In addition to the work going on with standardizing overdose death surveillance, consider standardizing surveillance for other measures relevant to drug use and overdose

• Standardize definition of sedative-hypnotic

Opioid Conversion Factors

Generic nameMME Factor

Generic name

MME Factor

BUPRENORPHINE 10MORPHINE 1

BUTORPHANOL 7NALBUPHINE 1

CODEINE 0.15 OPIUM 1

DIHYDROCODEINE 0.25OXYCODONE 1.5

FENTANYL 100OXYMORPHONE 3

HYDROCODONE 1PENTAZOCINE 0.37

HYDROMORPHONE 4PROPOXYPHENE 0.23

LEVORPHANOL 11TAPENTADOL 1

MEPERIDINE 0.1TRAMADOL 0.1

METHADONE 3

Sedative-Hypnotic FactorsGeneric Name VME Factor Generic Name VME FactorAlprazolam 20 Halazepam 0.5

Chlordiazepoxide 0.4 Lorazepam 10

Clobazam 0.5 Midazolam 1

Clonazepam 20 Oxazepam 0.5

Clorazepate 0.667 Prazepam 0.667

Diazepam 1 Quazepam 0.5

Estazolam 5 Temazepam 0.5

Flurazepam 0.4 Triazolam 20

Eszopiclone 0.333 Zolpidem 0.5

Zaleplon 0.5 Zopiclone 0.667