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2016 West Virginia Overdose Fatality Analysis:
Healthcare Systems Utilization, Risk Factors, and Opportunities for Intervention
Christina Mullins, DirectorOffice of Maternal, Child and Family Health
Bureau for Public HealthDecember 21, 2017
Drug Overdose Rates by State
1
US Resident Overdose Deaths by State, 2015
West Virginia vs. United States
2
11.512.9
15.1
18.822.3
20.422.4
25.725.9
28.9
36.3
32.0 32.2
35.5
41.5
6.88.2 8.9 9.4 10.1
11.5 11.9 11.9 11.9 12.313.2 13.1 13.8
14.716.3
0
5
10
15
20
25
30
35
40
45
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Per 100,000
2001-2015 Resident Drug Overdose Mortality RateWest Virginia and United States
WV
Data Source: WV Health Statistics Center, Vital Surveillance System and CDC Wonder.Rates are adjusted by age to the 2000 US Standard Million.
Purpose
3
Create a model
Identify risk factors
Identify opportunities for intervention
Methods
4
881
Preliminary Occurrence
Deaths
830
Preliminary Resident Deaths
(Matched against death records, CSMP,
Medicaid, EMS, BBHHF, and Corrections)
Interactions with Health Systems
5
Healthcare systems included BBHHF, EMS, and CSMP. Neither Medicaid or Corrections were included.
• 81% of decedents interacted with one or more systems.• Just under 40% of decedents interacted with only one system.
22%38%
30%
10%
78%
Males: Interactions with Healthcare Systems
None One Two Three
13%
39%
30%
18%
87%
Females: Interactions with Healthcare Systems
None One Two Three
Number of Drugs at Time of Death
6
• Females were more likely than males to have more than one drug in their system at their time of death.
One 10%
Two 27%
Three28%
Four17%
Five10%
Six Plus8%
Females: Number of Drugs at Time of Death
One 16%
Two 31%
Three25%
Four 14%
Five10%
Six Plus4%
Males: Number of Drugs at Time of Death
Drugs at Time of Death
7
Diversion
8
8%
23%
31%
20%
11%
1%
8%
24%
28%
15%
10%
2%
0%
5%
10%
15%
20%
25%
30%
35%
15-24 25-34 35-44 45-54 55-64 65+
Decedents Positive for a Controlled Substance at
Death but no Prescription by Gender and Age
Male Female
A total of 272 decedents (33%) tested positive for a controlled substance, but had no prescription at their time of death.
Decedents with CSMP Interaction
9
91%
9%
Decedents with CSMP Interaction
CSMP History No CSMP History
The West Virginia Board of Pharmacy’s Controlled Substances Monitoring Program (CSMP) documents the dispensing of Schedule II-IV controlled substances.
CSMP History at Point in Time Intervals
10
506
348
323
289
245
199
253
197
182
162
156
133
0 50 100 150 200 250 300 350 400 450 500 550
Ever
12 month
9 month
6 month
3 month
30 Day
CSMP History at Point in Time Intervals before Death by Gender
Females Males
Nearly half (49%) of all female decedents filled a prescription within 30 days of death, compared to 36% of males.
Number of Prescriptions by Drug Category
11
0
100
200
300
400
500
12 Months 9 Months 6 Months 3 Months 1 Month
Number of Prescriptions Before Death by Drug Category
Opioid Benzodiazepine Stimulant Other
Opioids and benzodiazepines were the most common controlled substance prescriptions filled by decedents in the 12 months prior to their death.
Prescriber and Pharmacy Utilization
12
• Decedents were three times more likely to have three or more prescribers as compared to the overall CSMP population for 2016 (9% versus 3%).
• Decedents were more than 70 times likely to have prescriptions at four or more pharmacies compared to the overall CSMP population for 2016 (7% vs. 0.1%).
EMS Administered Naloxone
13
29%
49%
8%14%
71%
Decedents with EMS Administered Naloxone
No Interaction with EMS No Naloxone
Naloxone > 48 Hrs Before Death Naloxone < 48 Hrs Before Death
There may be a disparity in the overall emergency response to West Virginians older than 65 that warrants further study.
Medicaid Eligibility
14
71%
29%
Medicaid Eligibility atAny Time 12 Months Prior to Death
Medicaid No Medicaid
According to the Kaiser Foundation, only 23% of West Virginia’s overall adult population ages 19-64 have Medicaid.
Medicaid Major Diagnostic Categories
15
51 4944
4036
64 63
5246
5156 54
4743 42
0
20
40
60
80
Symptoms,Signs, and Ill-
DefinedConditions
Mental Disorders Diseases of theMusculoskeletal
System andConnective
Tissue
Injury andPoisoning
SupplementaryClassification of
FactorsInfluencing
Health Statusand Contact withHealth Services
Major Diagnostic Categories with the Most Medicaid Eligible Decedents
Represented
Males Females Total
Medicaid Utilization
16
85%
15%
Percentage of Decedents Utilizing Medicaid within 12 Months Prior to
Death
Interaction
No interaction
Excludes claims within < 48 hours of death.
Low (≤30)30%
Medium (31-60)
20%
High (61-90)13%
Very High (>90)37%
Number of Medicaid Claims Prior to Death
Excludes pharmacy claims and claims within < 48 hours of death.
Utilization of Medicaid for Emergency Department (ED) Visits
17
9%
22%
69%
Emergency Department Utilization Among Decedents
within 48 hrs
Only 1 visit
2 or more visits
81%
12%3% 4%
Emergency Department Utilization by Number of Visits
between 1-5
between 6-10
between 11-15
>15
68%
32%
Medicaid Decedents with an ED Visit within 12 Months of Death
Yes
No
Medical services have the potential to reach a significant portion of individuals at risk of fatal overdose. Implementation of the Medicaid 1115 Waiver will expand opportunities for treatment and recovery services.
Corrections History by Gender
18
44%
43%
13%
56%
Corrections History by Gender
None Males with History Females with History
Officials from the WV Department of Military Affairs and Public Safety reported that there is not a uniform strategy for identifying how people with a substance abuse disorder are referred to services in their community.
Death After Incarceration
19
464 Interacted with
Corrections (Jail, Prison, Parole)
157 One Contact with Corrections
in the 12 Months Prior to Death
42 (27%) Died within 30 days of the Last Corrections Contact (Regional jail was the last
contact for the majority of decedents (88%) with a
corrections history.)
• 46% with some high school education died within 30 days.
• 32% of decedents that were never married died within 30 days.
Select High Risk Factors
20
Males
(67%)
35-54 Years of Age
(54%)
HS Education or Less
(79%)
Unmarried
(75%)
Blue Collar Occupations
Decedents by Industry Type
21
Recommendations for Healthcare Providers
22
• Be prepared to offer screening, referral, and/or treatment.
• Continuing education opportunities that help identify risk factors for overdose death and retain individuals in substance abuse treatment.
• Require prescribers to run a CSMP report on each patient prior to prescribing any Schedule II drugs, any opioids, and any benzodiazepines.
• Prescribers should consider offering naloxone for individuals at increased risk for opioid overdose.
CSMP Recommendations
23
• Enhance CSMP Advisory Committee legislation to identify abnormal or unusual prescribing and dispensing patterns and to permit sharing this data with appropriate professional licensing boards and other agencies.
• Develop CSMP policies and procedures for proactive reports to alert prescribers about the increased risk of overdose and potential misuse or diversion for those individuals known to the CSMP.
Other Recommendations
24
• Corrections officials should work with judges to assure naloxone availability, treatment referral, and peer supports at release of incarceration.
• Healthcare providers and the public may benefit from education regarding overdose signs and symptoms. This education should include information specific to individuals older than 65 years to increase the chance that someone will call emergency services and that appropriate administration of naloxone is offered.
Contact
Christina Mullins, Director
Office of Maternal, Child and Family Health
West Virginia Department of Health and Human Resources
Bureau for Public Health
350 Capitol Street, Room 427
Charleston, WV 25301
Email: Christina.R.Mullins@wv.gov
Phone: 304-356-4392
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