Karl Williams, MD, MPH

Karl Williams, MD, MPH

Medical ExaminerAllegheny County

The Overdose Problem in Allegheny County2008 - 2011

Allegheny CountyOverdose Prevention

Coalition

July 31, 2012

Karl E. Williams, MD, MPHChief Medical Examiner

Allegheny County

National Statistics

Scope of the National Problem• In the United States in 2007, unintentional poisonings were the second

leading cause of injury death (after motor-vehicle crashes)• Approximately 93% of all unintentional poisoning deaths were caused by

drug poisoning• In Florida, the nonsuicidal poisoning death rate increased 325% (1990 -

2001)• Recent trends in Florida (2003 – 2009)

– The number of annual deaths in which medical examiner testing showed lethal concentrations of one or more drugs increased 61.0%

– The greatest increase was observed in the death rate from oxycodone (264.6%), followed by alprazolam (233.8%) and methadone (79.2%).

Florida Overdose Data – 2003 - 2009

ACOME Drug Deaths as % of Morgue Cases

2011 2010 2009 2008 2007 20060.00%

5.00%

10.00%

15.00%

20.00%

25.00%

22.10%

19.62%18.99%

20.80%

18.70%

17.08%

Drug Deaths as % of Morgue Cases

Drug Death as % All Morgue Cases

ACOME Drug Deaths as % of Accidental Deaths

2011 2010 2009 2008 2007 20060.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

60.42%58.06% 57.77% 56.63%

49.89% 48.23%

Drug Deaths as % of Accidental Deaths

Drug Death as % Accidental Deaths

ACOME Drug Deaths by Age Group

0 thru 19 20 thru 24 25 thru 29 30 thru 34 35 thru 39 40 thru 44 45 thru 49 50 thru 54 55 thru 59 60 thru 69 70 or >0.00%2.00%4.00%6.00%8.00%

10.00%12.00%14.00%16.00%18.00%

3.14%

5.83%

11.66%

8.07%10.31%

13.45%15.25%

17.04%

10.31%

4.04%

0.90%

2009 % of Drug Deaths per Age Group


10.00%12.00%14.00%16.00%18.00%20.00%

2.97%

9.75% 9.32%

5.08%

8.90%

16.10%18.64%

15.68%

9.32%

2.54% 1.69%


ACOME Drug Deaths by Age Group


10.00%12.00%14.00%16.00%18.00%

2.30%

6.13%

11.49%12.64% 12.26%

13.41%

16.86%

13.41%

7.28%

4.21%



10.00%12.00%14.00%16.00%18.00%20.00%

1.76%

6.61%

11.01% 10.57%8.81%

12.78%14.10%

17.18%

11.01%

4.41%1.76%


ACOME Drug Deaths by Race/Sex

White Black Other0

20406080

100120140160 151

201

76

13

2011 Drug Deaths by Race / SexMale Female

White Black Other0

20406080

100120140 124

28

1

63

11


ACOME Drug Deaths by Race/Sex

White Black Other0

20406080

100120140 131

28

2

57

5


White Black Other0

20406080

100120140160 144

19

56

16


Figure 2. Number of drugs listed on death certificates, unintentional poisonings, Allegheny County, 2008-2010

127%

2 or 352%

4+21%

ACOME Drug Deaths TotalSingle or Combined

Case Year

Total Drug Deaths

1 Drug

2 Drug

3 Drug

4 Drug

5 Drug

6 Drug

7 Drug

2011 261 89 72 56 27 12 2 32010 227 61 69 52 28 9 1 72009 223 52 57 61 24 20 3 62008 235 81 56 58 22 13 2 3

ACOME Accidental Overdose Cases

Cocaine; 93

Alcohol; 66

Heroin; 62

Morphine; 49

Methadone; 37

Alprazolam; 28

Oxycodone; 19Citalopram; 18

2008 Top 8 Drugs FoundSingle or Combined OD

CocaineAlcoholHeroinMorphineMethadoneAlprazolamOxycodoneCitalopram


Cocaine; 76

Heroin; 63

Alcohol; 61Morphine; 40

Alprazolam; 39

Methadone; 38

Oxycodone; 33

Hydrocodone; 25


CocaineHeroinAlcoholMorphineAlprazolamMethadoneOxycodoneHydrocodone


Cocaine; 86

Alcohol; 56

Heroin; 50Morphine; 48

Oxycodone; 40

Alprazolam; 39

Methadone; 32

Diazepam; 20


CocaineAlcoholHeroinMorphineOxycodoneAlprazolamMethadoneDiazepam


Heroin; 95

Cocaine; 83

Alcohol; 60

Oxycodone; 51

Alprazolam; 41

Methadone; 26

Diazepam; 24

Morphine; 24


HeroinCocaineAlcoholOxycodoneAlprazolamMethadoneDiazepamMorphine

Death Certification Process - OD• Full Autopsy• Submit toxicology specimens– Blood – heart and femoral– Urine– Eye fluid– Bile

• Determine active drugs found in various specimens• Certify death as due to

– Single drug eg. Cocaine– Multidrug toxicity

Method problems

• There is no universally accepted standard for death certification– No accepted postmortem interpretive levels– No true science to multidrug intoxication– Issue of post-mortem re-distribution– No “SOP” dictating how to evaluate the significance of

different drugs in a mixture• Deaths can also be certified as Undetermined– Can significantly effect Suicide rates

• Detection limits decrease with every passing year– mg/ml to mcg/ml to nanogram/ml

Method problems – Heroin v. Morphine

• Heroin undergoes a rapid breakdown to 6-MAM (6 monoacetylmorphine)– 6-MAM found more frequently in either blood or urine

than heroin– If found in any substrate we can know that heroin was

ingested• Since morphine has a considerably longer half-life it

is commonly the only compound found

Metabolism of Heroin

6-MAMA

t ½ = 9 mins.

t½ = 39 mins.

t½ = 4 to 6 hours

Reclassification Process• Case by case review of secondary information– Evidence of drugs at the scene – stamp bags– Evidence of injection sites

• Recent• Healed linear scars – “tracks”

– History of prior abuse– NO evidence of pharmaceutical morphine

• If morphine is found and one of the above holds true death was reclassified as being due to heroin

Compliments to Kristen Mertz, MD - GSPH

Heroin: bricks, bundles, stamp bags…

Paraphenalia

Special case of codeine

• Codeine also breaks down to morphine but can occur as an additive to heroin (t½ = 3-5h.)

• When codeine is consumed as the primary drug the ratio of codeine to morphine is predictable

Figure 3. Most common substances detected by toxicology, unintentional drug overdose deaths, Allegheny County, 2008-2010

Morphine

Cocaine*

Ethanol

6-MAM

Codeine

Alprazolam

Methadone

Oxycodone

Hydrocodone

Fentanyl

Citalopram

Diazepam05

101520253035404550 47

3834

2419 19 17 16

139 8 7

% o

f dea

ths

*Cocaine metabolites include benzoylecgonine, ecgonine methyl ester, cocaethylene

Figure 1. Most common drugs listed on death certificates, unintentional drug overdose deaths, Allegheny County, 2008-2010

CocaineHeroin

Alcohol

Morphine

Methadone

Alprazolam

Oxycodone

Hydrocodone

Fentanyl

Diazepam

CitalopramCodeine

05

10152025303540 38

27 26

2016 16

138 8 6 6 5

38

61

Listed on death certificate After reclassification

% o

f dea

ths

Summary• Allegheny County still has a relatively “traditional” pattern of

drugs of abuse– Predominance of heroin and cocaine– Early rise of more modern synthetics in comparison with

other parts of the U.S.– Only now beginning to see penetrance of “designer drugs”,

at least as contributing to overdose deaths• Heroin incidence in Allegheny County has been

underestimated by prior classification schemes

Acknowledgements

• Kristen Mertz, MD, MPH – Department of epidemiology/GSPH/University of Pittsburgh

• Patricia Rekiel – Computer Analyst, ACOME• Jennifer Jennsen – Chief Toxicologist, ACOME

Documents

Karl Williams, MD, MPH