Utilization of GIS to identify ‘hot spot’ zip codes for prescription fatal drug overdoses in Maricopa County By William McConahey

Why is it a public health and social concern? Poisonings became the leading cause of injury death in the US (2008)1 Most poisoning deaths due to drugs1 Last 3 decades drug poisoning deaths have increased 7x from 1980 to 20131 51% of all drug poisoning deaths are related to RX drugs- opioid pain relievers (OPR) were the majority (75%)1

The danger of OPR abuse OPR1 Commonly used and highly available Pain- hydrocodone, methadone, oxycodone More OPR deaths >> than heroin & cocaine combined. A precursor to heroin use Each day, 44 people in the US die from OPR 16,000 per year, increase 4x since 1999 (2014)

Drug poisoning trends in the United States, 1980-2010 Death Rates2 h Rates Number of overdoses BY INTENT2

Percentage of pills prescribed by drug type in arizona, 20123 RX misuse and abuse in Arizona Quick facts Percentage of pills prescribed by drug type in arizona, 20123 AZ is 12th highest state in US for RX drug misuse and abuse among 12+ (NSDUH, 2013). AZ is 12th highest state for drug overdose mortality (CDC, 2014) 58% of pills prescribed in AZ are opiates

The AZ RX Misuse & Abuse Initiative Multi-agency Approach3 Stakeholder Collaboration Goal3 Reduce RX nonmedical misuse, abuse, and deaths by 18% by 2018 Strategies3 Reduce illegal acquisition/diversion of RX Promote responsible prescribing/dispensing RX Enhance RX practices/policies in law enforcement Increase public awareness about RX misuse Increase assessment/referral to treatment

Overview of countywide RX monitoring initiatives Awarded the Harold Rogers Prescription Drug Monitoring Grant from U.S. Department of Justice (2014)3 Previously piloted in Yavapai, Pinal, Graham/Greenlee, & Mohave3 Based on criteria: evidence of RX problem, willingness to use data-driven decision making, and capacity for implementation By end of 2-year pilot study, deaths and ER visits were reduced and prescription drug monitoring program (PDMP) usage & RX awareness increased

Maricopa County implementation of AZ RX Misuse and Abuse Initiative Partnership for Arizona RX misuse and abuse initiative Arizona Criminal Justice Commission (ACJC) Mercy Maricopa Integrated Care Maricopa County Department of Public Health (MCDPH) MCDPH focus increase public awareness patient education gather data regarding nonmedical misuse and abuse of drugs resulting in fatal and non-fatal overdoses Office of Epidemiology Utilize GIS to find areas in county with highest number of deaths

Study purpose Identify patterns and trends for fatal overdoses in Maricopa County from 2008-2013 Analyze opiate frequency and rates within zip codes

Methodology Vital Data (Death Certificates) for Maricopa County Residents from 2008-2013 ICD-10-CM codes were used to identify primary cause of death for poisonings (X40--X44, X60--X64, X85, or Y10--Y14.) All other 20 diagnosis fields were analyzed for the following drug overdoses: Opiate (T40.2-.4), Benzodiazepine (T42.4), Cocaine (T40.5), and Heroin (T40.1) Used ArcGIS software to map zip codes, and excluded P.O Boxes and to manipulate and analyze original data

Kernel Density Tool in Spatial Analyst toolbox calculates prevalence per unit area from point or linear feature using a kernel function to fit a smooth surface to each point or line Calculates points that fall within the neighborhood considered in calculating density

Kernel Density

Kernel Density example Group of points are converted into a single raster

Hot Spot Analysis Tool in Spatial Statistics toolbox identifies statistically significant hot spots and cold spots using Getis-Ord Gi* statistic based on a null hypothesis Creates a new output feature class with a z-score, p-value, and confidence level P-value-probability of random spatial pattern Z-score-standard deviation from mean value

Hot Spot Analysis

Hot Spot Analysis

Hot Spot Analysis example

Drug death numbers in Maricopa County, AZ (2008-2013) Note: Drugs in this graph are combined total of deaths due to benzodiazepine, cocaine, heroin, and opiate use.

Opiates Emphasis on opiates due to more widespread use than other drugs Questions to address What areas (zip codes) have the highest fatal overdoses for opiates from 2008-2013? Do socioeconomic factors have an effect on fatal opiate overdoses?

Density map for drug deaths

Zip codes with highest drug death frequency

Zip Codes with highest frequencies for both studied drugs and opiate deaths: 85018, 85032, 85225

Frequency of opiate deaths by zip code PHOENIX NON-PHOENIX Zip Code Frequency 85018 29 85032 28 85022 22 85021 20 85023 Zip Code Frequency 85345 28 85301 85225 24 85281 22 85308 21

Poverty rate in zip codes with opiate death hot spots 85308 7.3 85225 16.5 85302 85018 85345 16.8 85022 17.4 85281 38.9 85301 39.1 Median hot spot poverty rate: 16.7% (Countywide poverty rate: 16.7%) Note: 2010 poverty rate is official figure from US Census Bureau

Median household income in zip codes with opiate death hot spots 85301 27,267 85302 43,477 85022 45,606 85345 45,886 85018 52,389 85225 56,414 85281 57,348 85308 68,796 Median household income for hot spots :$50,425 Median household income for Maricopa County: $53,596

Frequency changes in opiate deaths for Maricopa County

Frequency changes of opiate deaths in hot spot zip codes (2008-2013)

Summary of opiate death frequency Was there a significant relationship between poverty rate, median household income, and opiate death frequency? Based on existing data, no Was there a general drop in opiate deaths between 2008 and 2013? Yes

Drug death rate by zip code

Zip Codes with highest rates for studied drug deaths and opiate deaths: 85004, 85013, 85014, 85342

Opiate death rate by zip code PHOENIX NON-PHOENIX Zip Code Rate 85004 120.8 85018 80.4 85014 76.7 85023 64.0 85013 57.0 Zip Code Rate 85342 126.7 85264 80.1 85378 70.1 85302 54.2 85306 53.7

Poverty rate in zip code with opiate death rate hot spots 85023 16.2 85342 16.6 85018 85014 24.4 85264 24.5 85004 39.8 Median poverty rate: 20.5% (Countywide poverty rate: 16.7%) Note: Poverty rate was based on 2010 Census data.

Median household income in zip codes with opiate death rate hot spots 85004 26,008 85014 41,903 85342 42,375 85023 47,200 85018 52,389 85264 56,842 Median household income in hot spots: $44,788 Median household income for Maricopa County: $53,596

Rate changes in opiate deaths in Maricopa County

Rate changes in opiate deaths in hot spot zip codes

Summary of opiate death rates Was there a significant relationship between poverty rate, median household income, and opiate death rate? No, although poverty rate was higher and median household income was lower compared to areas of high opiate death frequency Did the rate of opiate deaths drop between 2008 and 2013? According to the existing data, yes

Findings and Conclusions The top zip codes for opiate death frequency and rates were different, probably due to different population numbers within each zip code Frequency and rates of deaths due to opiate use declined between 2008 and 2013 Poverty rates and median household incomes varied greatly within hot spots, which indicates they may be a factor, but not a significant factor, in determining opiate death occurrences within a given population

William McConahey GIS Epidemiologist Maricopa County Department of Public Health 602-372-2776 williammcconahey@mail.maricopa.gov

Footnotes 1Warner M, Chen LH, Makuc DM. Drug Poisoning Deaths  in the United States, 1980–2008. NCHS data brief, no 81. Hyattsville, MD: National Center for Health Statistics. 2011. Centers for Disease Control and Prevention. Injury Prevention & Control: Prescription Drug Overdose. (2015). Available from URL http://www.cdc.gov/drugoverdose/data/overdose.html

Footnotes 2Jones C. Prescription Drug Abuse and Overdose in the United States.  (2013). Available from URL https://secure.in.gov/attorneygeneral/files/Jones_Indiana_RX_Meeting_-_CJONES(5).pdf 3Malone S. A Multi-Systemic Approach for Address for Arizona’s “ Silent Epidemic”. (2014). Arizona Criminal Justice Commission: Statistical Analysis Center. 2014.