Overlapping Opioid and Benzodiazepines in Delaware: A Baseline Report to inform Delaware DOJ 9-Point Plan (September 5, 2017) Report prepared by: Tammy L. Anderson, Guanwen Qi, Jascha Wagner and Steve Martin Center for Drug and Health Studies Funded by BJA Harold Rogers Program FY2014 Award #2014-PM-BX-0002 through the Criminal Justice Council And by Contract 18-106 from the Delaware Department of Public Health

We prepared the following slides to address Point #5 in the recent Delaware DOJ 9-point plan to combat the opioid problem in Delaware. Point #5 focuses on more understanding of overlapping opioid/benzodiazepine prescribing and consequences. This plan was announced by Attorney General Matt Denn at a news conference on September 5th, 2017. Our report begins with an overview of death report (Department of Forensic Science (DFS) information on deaths due to combinations of opioids and benzos, followed by PDMP data we matched to them. CDHS currently has PDMP data from January 1, 2013 – March 31, 2015 and January 2016 through June 30, 2016. We also include some indicators on prescribing overlapping opioids and benzos by Delaware prescribers.

In 2016, there were 22 deaths resulting from combined benzodiazepine/opioid combinations. This represents 7% of all 2016 drug-related deaths.

A demographic comparison shows no difference in average age of decedents (42 vs 41) between the two groups. Whites dominated both opioid/benzo deaths as well as all other deaths. White males dominated 2016 deaths, with an exception in opioid/benzo deaths where male and female deaths were essentially tied at 11 and 10 respectively.

2016 Overdose Deaths in Delaware: County of Decedent Figure 3. 2016 Overdose Deaths in Delaware: County of Decedent About 59% or 181 of overdose death decedents in 2016 resided in New Castle County (NCC). NCC dominated both opioid/benzo combination deaths and those from all other drug causes. New Castle county reported the highest rate (i.e., 32.75 deaths per 1,000,000 residents), for opioid/benzo combinations in 2016, while Sussex county reported the highest rate (i.e., 366.61 deaths per 1,000,000 residents) for all other drug causes. The proportion of deaths due to opioid/benzo combinations and all other drugs in these two counties was similar to NCC.

We matched 2016 deaths to their prescription drug histories in the Delaware PDMP for January 1, 2013- March 31, 2015 & January 1 – June 30, 2016. 2016 decedents from overlapping opioid/benzo combinations had many more prescriptions (67 per decedent), on average, compared to decedents (51 per decedent) from all other drug causes.

CDHS currently has PDMP data from January 1, 2013 – March 31, 2015 and January 2016 through June 30, 2016 These ten drugs are the top ten prescribed to decedents dying from opioid/benzo combinations in the PDMP data held by CDHS. The ten drugs comprise 50% of all drugs prescribed Benzo formulations are the top three drugs prescribed. Benzos dominate decedents’ prescription histories. Percentages rounded to tenths. Based on 306 cases provided by Delaware’s Division of Forensic Science (DFS)

CDHS currently has PDMP data from January 1, 2013 – March 31, 2015 and January 2016 through June 30, 2016 These are the ten drugs prescribed to decedents dying from all other causes in the PDMP data held by CDHS. They comprise 37% of all drugs, indicating greater variation in prescription histories than opioid/benzo decedents. Percentages rounded to tenths Based on 306 cases provided by Delaware’s Division of Forensic Science (DFS)

Overlapping Opioid/Benzodiazepine Prescriptions in the Delaware PDMP % of patients receiving opioids and benzodiazepines medications at the same time (Jan 1 – June 30, 2016) • 1,307 Delaware prescribers issued 50,493 prescriptions involving an opioid-benzo Overlap between January 1 – June 30, 2016. These prescribers wrote the prescriptions to 10,690 Delaware recipients or about 5.1% of the 210,384 Delaware recipients captured in the DE PDMP during this time period. If requested, we can provide (in a confidential file) the names of these prescribers and how many overlapping prescriptions they each wrote .

Most drugs were paid for via commercial insurance, followed by Medicaid for both decedents dying from benzodiazepine/opioid combinations AND all other causes (percentages calculated per group). Decedents who died from opioid/benzo combination deaths more often paid for their drugs with Medicaid or cash than those dying from other drug causes. The reverse is true for commercial insurance: those who died from other drug causes more often paid for their drugs via commercial insurance (percentages calculated per group). Based on 306 cases provided by Delaware’s Division of Forensic Science (DFS)

This map shows the rate of overlapping opioid and benzodiazepine prescriptions per 1,000 census tract residents between January 1 and July 10, 2016. The mean opioid/benzo overlap rate is 64 prescriptions per 1,000 tract residents. This distribution is highly skewed, reporting a standard deviations of 161 The map shows census tracts shaded according to their distance from the tract average opioid/benzo overlapping Rx rate. 9% of the tracts reported overlap rates nearly 1 standard deviation above the mean. Most of these “hot spot” opioid/benzo overlap tracts are in New Castle county, while a few others are in the Dover and beach resort areas.

Conclusions 2016 deaths reported to DFS from opioid/benzo combinations are a small minority (about 7%) of all overdose deaths. Like all other overdose deaths in Delaware, they are concentrated in New Castle county, are mostly white with an average age in the early 40s. However, there is more gender equity in opioid/benzo death than in all other drug overdose deaths, indicating the female overdose rate could be especially improved with an intervention targeting opioid/benzo overlap prescribing. Decedents from opioid/benzo combinations have PDMP prescriptions histories with greater benzodiazepines than decedents from all other drug causes. This suggests that reducing opioid/benzo combination deaths could should prioritize benzodiazepine prescribing as well as that for opioids. Deaths due to opioid/benzo combinations may be more prominent among lower-class folks reliant on Medicaid. We recommend additional analyses for earlier years to assess change over time and further drilling down for other neighborhood effects and patterns. Finally, correlational and predictive analysis are possible and recommended to investigate individual and community factors driving these deaths and prescribing patterns.