1

Prescription Drug Overdose Mortality Surveillance Review

Len Paulozzi, MD, MPHDivision of Unintentional Injury Prevention

National Center for Injury Prevention and ControlCenters for Disease Control and Prevention

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

National Center for Injury Prevention and ControlDivision of Unintentional Injury Prevention

2

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

1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 20100

5

10

15

20

25

Motor Vehicle Traffic Poisoning Drug Poisoning (Overdose)

Year

Dea

ths

per

100,

000

popu

lati

on

3

Drug overdose deaths by major drug type,

US, 1999-2010

CDC/NCHS National Vital Statistics System, CDC Wonder.

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

Opioids HeroinCocaine Benzodiazepines

Year

Num

ber

of D

eath

s

16,651

4

Outline of presentation 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

4

5

Death Certificate Information entered by the medical certifier

determines the cause of death Text converted to numeric codes largely by

computer.

CAUSE OF DEATH (See instructions and examples) Approximate interval: Onset to death32. PART I. Enter the chain of events - - diseases, injuries, or complications - - that directly caused the death. DO NOT enter

terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.

IMMEDIATE CAUSE (Final disease or condition resulting in death) a. MULTIPLE DRUG INTOXICATION

Sequentially list conditions, if any, leading to the cause listed on line a. Enter the UNDERLYING CAUSE (disease or injury that initiated the events resulting in death) LAST

Due to (or as a consequence of):

b.

Due to (or as a consequence of):

c.

Due to (or as a consequence of):

d.

PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in Part I.

33. WAS AN AUTOPSY PERFORMED? Yes No

34. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE THE CAUSE OF DEATH? Yes No

35. DID TOBACCO USE CONTRIBUTE TO DEATH?

Yes Probably No Unknown

36. IF FEMALE: Not pregnant within past year Pregnant at time of death Not pregnant but pregnant within 42 days of death Not pregnant but pregnant 43 days to 1 year before death Unknown if pregnant within the past year

29. MANNER OF DEATH Natural Pending Accident Investigation Suicide Could not be Homicide Determined

38. DATE OF INJURY(Mo/Day/Yr)(Spell Month)

39. TIME OF INJURY 40. PLACE OF INJURY (e.g., Decedent’s home, construction site, restaurant, wooded area) HOME

41. INJURY AT WORK?

Yes No

42. LOCATION OF INJURY: State: City or Town: Street & Number: Apartment No. Zip Code:

43. DESCRIBE HOW INJURY OCCURREDDRUG INGESTION

44. IF TRANSPORTATION INJURY, SPECIFY Driver/Operator Passenger Pedestrian Other (Specify)

To B

e C

ompl

eted

By:

ME

DIC

AL

CE

RTI

FIE

R

X

7

What is an underlying cause? 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

8

Definition of a drug 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.

9

Accuracy of death certificate codes 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

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

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ICD10 Codes for Drug Poisoning

Drug Type Unintentional

Suicide

Undetermined

Homicide

Nonopioid analgesics, antipyretics and anti-rheumatics

X40 X60 Y10

X85

Sedative-hypnotic, psychotropic

X41 X61 Y11

Narcotics and psychodysleptics (hallucinogens), NOS

X42 X62 Y12

Other drugs acting on CNS

X43 X63 Y13

Other and unspecified drugs

X44 X64 Y14

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Comparability with ICD-9 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.

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CDC “Drug Poisoning” Definitions 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.

13

Death Investigation Systems 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

County-based coroner OfficesCounty-based mixture of ME and Coroner OfficesCounty/District-based ME (physician) OfficesCentralized State ME Office

Sources: National Institute of Justice, Scientific Working Group on Medical Death Investigation, Death Investigation Systems, 2011Bureau of Justice Statistics, Census of Medical Examiner and Coroner Offices, 2004

MT

WY

ID

WA

OR

NV

UT

CA

AZ

ND

SD

NE

CO

NM

TX

OK

KS

AR

LA

MO

IA

MN

WI

IL IN

KY

TN

MS AL GA

FL

SC

NC

VAWV

OH

MI

NY

PA

MDDE

NJ

RI

MA

ME

VTNH

AK

HI

Death investigation systems, 2004

*

*

*CT

*

*

**

*

*

*

*

*

*

**

* *

*

*

**

*

*

* State ME

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Pitfalls in reporting underlying cause of death

Unknown cause (R99 or Pending) Mental and behavioral disorders Intent

Pending certificates 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 percentpending 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

Source: NCHS, data from the National Vital Statistics System

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 20090

2

4

6

8

10

12

97

97.5

98

98.5

99

99.5

10099.9

98.9

97.5

99.8 99.8 99.899.6 99.7

99.9 99.8 99.9

Drug poisoning death rate/10_5

Percent non- pending

Drug poisoning deaths recorded as unknown-cause (R99) deaths, 15-54 years

old, California, 1999-2006

99 00 01 02 03 04 05 0602468

101214161820

Rate

per

100

,000

Unknown Cause

Unintentional Drug Poisoning

Unintentional motor vehicle traffic

Opioid analgesic overdose deaths and unknown-cause (R99) deaths, West

Virginia, 1999-2010

1999 2000 2001 20022003 2004 2005 2006 2007 2008 2009 20100

100

200

300

400

500

600

700

800

Num

ber

of d

eath

s

Unknown Cause

Opioid overdose

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

1999-2010

1999200020012002200320042005200620072008200920100

200400600800

100012001400160018002000

Num

ber

of d

eath

s

Unknown CauseOverdose

Source: CDC WONDER

Recommendations on pending deaths

• 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

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Deaths assigned to 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.

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

Map produced by CDC WONDERAge-adjusted rate per 100,000 for F11-16, F19

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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

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The issue of intent of injury 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

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Undetermined vs. unintentional drug poisoning crude mortality rates by

state, 2006

0 2 4 6 8 10 12 14 16 18 200.02.04.06.08.0

10.012.014.0

Unintentional drug poisoning mortality rate

Unde

term

ined

inte

nt

drug

poi

soni

ng m

orta

lity

rate

UTMD

ARIN

Percent of overdose deaths with undetermined intent, selected core

states, 2009-2010 State Percent

State Percent

AZ 7.9 OH 4.3CO 7.9 OK 6.6HI 19.9 OR 10.8KY 8.3 PA 5.1MA 5.6 RI 0.0MD 80.5 TN 6.7NC 4.6 UT 35.7NE 12.1 WA 5.9

States with centralized medical examiner systems shown in red.

Recommendations on reporting overdose mortality by intent

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.

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Defining Contributing Causes of Death

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Drugs as contributing causes 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

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Defining illicit and prescription drugs in ICD10

Prescription Drug Category ICD10 T codes

Illicit drugs (heroin, cocaine, LSD) T40.1, T40.5, T40.7-T40.9, T43.6Opioid analgesics T40.2-T40.4--- Other opioids (semi-synthetic) T40.2--- Methadone (synthetic) T40.3--- Other synthetic narcotic (synthetic)

T40.4

Benzodiazepines T42.4Antidepressants T43.0-T43.2All prescription drugs T36-T39, T40.2-T40.4, T41-T43.5,

T43.7-T50.8

Definitions of opiates and opioids

opioids

opiatespharmaceutica

l opioids

heroinopium

semi-synthetics:

codeine morphine oxycodone

hydrocodone

synthetics:

methadone,

fentanyl, tramadol

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Distinguishing “opioids” and “opiates” in mortality

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

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Pitfalls in reporting contributing causes of death from overdose

Causes of undercounting specific drugs Causes of overcounting specific drugs Assigning responsibility among multiple

drugs

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Lack of drug specification 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 State Percent State PercentAZ 80.2 OH 71.6CO 70.5 OK 96.2HI 82.9 OR 90.7KY 65.3 PA 46.2MA 96.7 RI 96.7MD 97.7 TN 78.2NC 92.4 UT 94.0NE 69.4 WA 92.4

States with centralized medical examiner systems shown in red.Source: Unpublished analysis by Margaret Warner of NCHS

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Percent of overdose deaths with 1+ drug specified against mortality rates

by state by type of overdose, 2008-2010

10 20 30 40 50 60 70 80 90 10005

1015202530

Overdose Linear (Overdose)Opioid overdose Linear (Opioid overdose)

Percent with drug(s) specified

Mor

talit

y ra

te/1

00,0

00

Opioid overdose deaths coded only as

“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.

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Some opioid-related deaths NOT included

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, 201016,651 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

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Possible contributors to over-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

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Multiple drugs contributing to an overdose death

Partitioning responsibility not possible Deaths counted more than once States vary in number of drugs coded per

death

45

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.

Opioid

Pain R

eliever

s (n=

16651

)

Antie

pilepti

c and A

ntipa

rkinso

nism Drug

s (n=17

17)

Benzo

diazep

ines (

n=64

97)

Barbi

turate

s (n=

296)

Antid

epres

sants

(n=38

89)

Antip

sycho

tic an

d Neu

rolep

tic Drugs

(n=1351

)

Other Psy

chotr

opic D

rugs (

n=24)

05

101520253035 29.4

6.2 3.79.1 10.5

6.4 8.3

Psychotherapeutic and CNS Pharmaceuticals

Perc

ent

46

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.”

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Using CDC WONDER 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

48

“Recommendations for 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, Acad Foren Path 2013; 3(1): 62-76 and 77-83.

Additional Information

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

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

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

Len Paulozzi, MD, MPHlpaulozzi@cdc.gov

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.

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