The Overdose Crisis: Allegheny County 2019

ACOPC Summer Conference July 18, 2019

Karl E. Williams MD MPHChief Medical Examiner

Allegheny County

National Medical Services (NMS)

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How to Query the DatasetsStep 1: Choose “View Overdose Death Data”

How to Query the DatasetsStep 2: Select County(s) and load data set.

*Counties will have variable years of data

How to Query the DatasetsStep 3: Choose Desired Years

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OverdoseFreePA Overdoses by Resident and Incident Zip Code

OverdoseFreePA Overdoses by Zip Code

Allegheny Allegheny and Westmoreland

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Allegheny CountyOverview

Allegheny County 2018 Data—Total

Allegheny County2018 Data—Resident Zip Codes

Allegheny CountyZip Code with Highest Number of Overdoses (2018)

15212 = 24 Overdose Deaths in 2018 Brighton Heights

Allegheny County Age Breakdown

2017 2018

Allegheny County Top Ten Drugs 2018

Allegheny County Heroin vs. Fentanyl

= Fentanyl = Heroin

Butler County Top Ten Drugs (2018) + AC (Insert)

AC – (2018)

Ethanol as Overdose Drug

2008 – 2019 (4,102)

2014 (306)

2019 (32)

Pennsylvania Opioid & Benzodiazepine prescriptions fall while MAT treatment rises

PennsylvaniaPrescription Opioids vs. Fentanyl

The Future? Ten scenarios - VOX

Ten Year Projection of Opioid Overdose Deaths

Where are we going from here?

Worst Cast Scenario Best Cast Scenario

• The best-case projection has fatal overdoses falling below 22,000 a year by 2027. But experts say reaching that level would require a major public investment in evidence-based treatment options and a concerted push among medical providers to control pain with non-narcotic therapies before trying prescription opioids

• By contrast, federal officials estimate that opioid abuse drains nearly $80 billion a year8 from the American economy because of expenses tied to health care, criminal justice, and lost productivity.

• The worst case scenario for opioid deaths forecast for 2027 is 40,652. The forecasted change is 23% since 2015 when it was 33,091.This curve assumes opioid deaths increase until a combination of increased naloxone access, decreased prescription opioids, and increased treatment lowers fatal overdoses

https://www.statnews.com/2017/06/27/opioid-deaths-forecast/

Scenarios for the Future

Drug Diversity

Drug DiversityOverdose Death Increase Follows Increase in Drug Diversity

KetamineBenefits and Risks

• Ketamine has shown clinical effectiveness for relieving treatment-resistant depression

• Within 40 minutes after a single infusion of ketamine, treatment-resistant depressed bipolar disorder patients experienced restored pleasure-seeking behavior that lasted up to 14 days (Lally et al., 2014)

• Ketamine has a history of recreational use and is a candidate for diversion

• Ketamine’s effects act through interactions with the glutamate and opioid receptor systems in the brain

KetaminePresence in Pennsylvania Overdoses

GabapentinBenefits and Risks

• Gabapentin is an anticonvulsant medication used to treat seizures and neuropathic pain

• ”Gabbies” are increasingly misused for euphoric recreational effects, typically alongside opioids, benzodiazepines, and alcohol (Smith et al., 2016)

• 49% higher overdose rate among gabapentin + opioid prescriptions than with opioids alone (Gomes et al., 2017)

GabapentinHistory

1993

Initial FDA approval for

treatment of partial seizures.

2016

United States’ 10th most

commonly prescribed

medication.

2004

(1) FDA approval for treatment of post-

herpetic neuralgia pain.

(2) Generic gabapentin available (Neurontin®

patent expired).

2000

FDA approval for partial

seizure in children from 3–12

years old.

GabapentinPresence in Pennsylvania Overdoses

LoperamideBenefits and Risks

• Sold over the counter as oral treatment for diarrhea which works as a peripheral opioid and does not affect the brain at normal doses

• Increased restrictions on Rx opioids may prompt some users to use loperamide as an over-the-counter withdrawal treatment—“The poor person’s methadone”) (MacDonald et al., 2015)

• Several reports of sometimes-fatal cardiotoxicity due to high-dose loperamide misuse have been published (Egglestone et al., 2016; Mukarram et al., 2016)

LoperamidePresence in Pennsylvania Overdoses

National Medical Services (NMS)

National Medical Services (NMS)

National Medical Services (NMS)

National Medical Services (NMS)

References

Eggleston, William; Clark, Kenneth H.; Marraffa, Jeanna M. (2016). "Loperamide Abuse Associated With Cardiac Dysrhythmia and Death". Annals of Emergency Medicine. 69 (1): 83–86. doi:10.1016/j.annemergmed.2016.03.047. ISSN 0196-0644. PMID 27140747.

Evoy KE, Morrison MD, Saklad SR (March 2017). "Abuse and Misuse of Pregabalin and Gabapentin". Drugs. 77(4): 403–426. doi:10.1007/s40265-017-0700-x. PMID 28144823.

Gomes T, Juurlink DN, Antoniou T, Mamdani MM, Paterson JM, & van den Brink, W (2017). Gabapentin, opioids, and the risk of opioid-related death: A population-based nested case–control study. PLoS medicine, 14(10), e1002396.

Lally N, Nugent AC, Luckenbaugh DA, Ameli R, Rosier JP, Zarate CA Jr. Anti-anhedonic effect of ketamine and its neural correlates in treatment-resistant bipolar depression. Transl Psychiatry 2014 Oct 14; 4:e469. [PMID: 25313512]

Mukarram, O.; Hindi, Y.; Catalasan, G.; Ward, J. (2016). "Loperamide Induced Torsades de Pointes: A Case Report and Review of the Literature". Case Reports in Medicine. 2016: 1–3. doi:10.1155/2016/4061980. ISSN 1687-9627. PMC 4775784. PMID 26989420.

MacDonald, R; Heiner, J; Villarreal, J; Strote, J (2 May 2015). "Loperamide dependence and abuse". BMJ Case Reports. 2015: bcr2015209705. doi:10.1136/bcr-2015-209705. PMC 4434293. PMID 25935922.

Medscape. (2015).Gabapentin New Drug of Abuse?

Smith RV, Havens JR, Walsh SL (July 2016). "Gabapentin misuse, abuse and diversion: a systematic review". Addiction. 111 (7): 1160–74. doi:10.1111/add.13324. PMC 5573873. PMID 27265421.

In Pain, A bioethicists struggle with pain Travis Reider

•Brendan Jeffrey Barstow

•And

• The staff at PERU

• Jan Pringle

• Lynn Mirigian

• the numerous others

ACKNOWLEDGEMENTS

Thank you! Questions are Welcome

Allegheny County Overdoses over Time

Kratom• Kratom is a tropical tree (Mitragyna speciosa) native to Southeast

Asia, with leaves that contain compounds that can have psychotropic (mind-altering) effects.

• A new study from the Centers for Disease Control and Prevention (CDC) found that kratom was a cause of death in nearly 100 people over a 17-month period -- a higher number than previously reported.

• dropped a plan to classify it as a controlled substance after public outcry in 2016.

Methamphetamine

• On Wednesday and Thursday (August 15 and August 16), more than 85 people in New Haven, Connecticut, overdosed on synthetic cannabinoids. In Washington, DC, last month, more than 300 people overdosed on the drugs, commonly called K2 or Spice, with similar cases reported in Baltimore, Brooklyn, and Los Angeles

Allegheny County Heroin vs. Fentanyl

2008-2017 2017

OverdoseFreePA Fentanyl Query

Allegheny CountyPrescription Opioids vs. Fentanyl