1. Overdoses on Prescribed Opioids in Massachusetts, 2013-2014*
AY Walley, MD, MSc,1,2 D Bernson, MPH,2 MR LaRochelle, MD, MSc,1 TC Green, PhD, MSc,1 L Young, MS, MA2 T Land, PhD2
1Boston Medical Center/ Boston University School of Medicine
2Massachusetts Department of Public Health
AMERSA 2017

2. Chapter 55

3. New Hampshire State Police Forensic Lab
Chapter 55

4. Heroin & Fentanyl Together
Fatal opioid overdoses often attributed to prescribed opioids rather than diverted or street opioids
Morphine
Oxycontin
Fentanyl patch
Here you see examples of morphine medication, heroin, pharmaceutical fentanyl and illicit fentanyl.
Heroin Alone
Heroin & Fentanyl Together
Fentanyl Alone

5. Study Aim
Among people who died from opioid-related overdose in Massachusetts, determine the proportion of deaths with actively prescribed opioids
where the days supply in the PMP overlaps the date of death and the opioid is in toxicology

6. Substance Use Treatment
Methods
Massachusetts Ch 55 dataset linked at individual level
legislative mandate to characterize opioid overdose
Massachusetts’ residents who died of an opioid-related overdose:
6/1/ /31/2015
PDMP
All Payer Claims
All residents with insurance
~ 6 Million
Death Certificates
Reduce the
Substance Use Treatment
Death Toxicology

7. Methods
Among Massachusetts’ residents who died of an opioid-related overdose between 6/1/2013 and 12/31/2015, we analyzed individually-linked opioid toxicology and Prescription Monitoring Program (PMP) records
Death and PMP records were available by specific date
Methadone maintenance patients were available by month
Claim for methadone administration from all payer claims database (HCPCS H0020) or
Bureau of Substance Abuse Services treatment data
Prescribed opioid overdoses definition:
decedent had an active prescription, based on the number of days supplied in the PMP, for the opioid present in the toxicology prior to or on the date of death
We also calculated the proportion of overdoses for which opioids prescribed in the PMP were not present in toxicology on the date of death
We categorized samples that had 6-mam or a combination of morphine and codeine in the same sample as “heroin.” Whereas those with morphine, but no 6-mam or codeine, were categorized as “morphine”

8. Demographics of cohort of opioid-related deaths
Analytic Cohort, opioid deaths with tox, n=2,916
Age, mean, median
39.4 (38)
Gender
Male
73%
Female
27%
Race
White
87%
Black
4.1%
Asian/PI
0.4%
Hispanic
7.7%
American Indian/Other
0.8%

9. Heroin and fentanyl are the most common opioids in toxicology at death

10. Opioids commonly prescribed within 1 year of death, but uncommonly prescribed at time of death
1. To the
2. What fraction of the Active Rx’s are buprenorphine or MMT?
I would like to further break these out:
No opioid prescription
Any bup or MMT
No bup or MMT, but opioid Rx for pain
Frequencies based on the number of days supplied in the PMP
At death: MME mean 134, min 2, 25th 30, median 90, 75th 120, max 960

11. Active prescriptions are uncommon at death, especially fentanyl
Prescribed opioid = Opioid with active prescription at death based on the # of days supplied in the PMP
MMT = Methadone Maintenance within 1 month of death

12. Oxycodone, methadone, buprenorphine are most common actively prescribed opioids at death
Fentanyl is not due to cell suppression rules at MDPH. There were 17 people who died with an active fentanyl prescription and fentanyl in toxicology. There were <5 people with an active fentanyl prescription who died without fentanyl in toxicology.
Methadone MT = Methadone Maintenance within 1 month of death

13. Opioids prescribed were commonly NOT present on overdose toxicology
Fentanyl is not due to cell suppression rules at MDPH. There were 17 people who died with an active fentanyl prescription and fentanyl in toxicology. There were <5 people with an active fentanyl prescription who died without fentanyl in toxicology.
Methadone MT = Methadone Maintenance within 1 month of death

14. Limitations
We did not incorporate opioid-specific information from death certificates because they were not systematically available or consistent
Methadone maintenance information available at the month level
Thus people who died in the month discharged from methadone are counted as being treated with methadone maintenance
We did not include non-opioid substances
e.g. benzodiazepines, alcohol, cocaine)
Emerging, but non-prescribed, opioids (eg, carfentanil, furanyl fentanyl) were not routinely tested and not included

15. Conclusions
Active prescriptions are uncommon at death, especially fentanyl
More likely illicitly made fentanyl than prescribed
Opioids commonly prescribed often not present on toxicology
People who die often not taking prescribed opioid
Except methadone – opioid with highest proportion prescribed, and thus lowest proportion diverted among people who die
Linking overdose toxicology to PMP can better attribute overdoses to:
prescribed opioids
diverted prescription opioids
heroin
illicitly-made fentanyl

16. Thank you! awalley@bu.edu

17. ICD-10 cause of death codes do not distinguish heroin from morphine or pharmaceutical from illicit fentanyl
T40.1 = heroin overdose,
T40.2 = natural and semi-synthetic opioids (e.g. prescribed morphine)
>> misclassification of heroin overdoses into T40.2 when only morphine is present
T40.3 = synthetic opioids, excluding methadone (e.g. fentanyl, prescribed or illicit)
6-MAM, the specific toxicology result for heroin, is helpful when present, but does not rule out heroin when it is absent
Commonly morphine is the only opioid substance detected after heroin overdose
The current coding of causes of death system does not clearly distinguish heroin from morphine deaths or pharmaceutical fentanyl from illictly made fentanyl deaths.
We categorized samples that had 6-mam or a combination of morphine and codeine in the same sample as “heroin.” Whereas those with morphine, but no 6-mam or codeine, were categorized as “morphine
We categorized samples that had 6-mam or a combination of morphine and codeine in the same sample as “heroin.” Whereas those with morphine, but no 6-mam or codeine, were categorized as “morphine
Harruff, R. C., F. J. Couper, and C. J. Banta-Green. "Tracking the opioid drug overdose epidemic in King County, Washington using an improved methodology for certifying heroin related deaths." Academy Forensic Pathology 5 (2015):

18. 2,916 opioid deaths with complete
Results
1/ /2015
5170 opioid deaths
6/ /2015
3,710 opioid deaths
6/ /2015
2,916 opioid deaths with complete
toxicology results
79%

19. Overdoses involving IMF are acute and rapid
CDC-Mass DPH mixed methods investigation that included death record reviews and qualitative interviews with people who use opioids and had either witnessed or survived an overdose
Illicitly manufactured fentanyl (IMF) responsible for opioid overdose deaths
“So, now what they [people selling illicit drugs] are doing is they’re cutting the heroin with the fentanyl to make it stronger. And the dope [heroin] is so strong with the fentanyl in it, that you get the whole dose of the fentanyl at once rather than being time-released [like the patch]. And that’s why people are dying—plain and simple. You know, they [people using illicit drugs] are doing the whole bag [of heroin mixed with fentanyl] and they don’t realize that they can’t handle it; their body can't handle it.”
Overdoses involving IMF are acute and rapid
“A person overdosing on regular dope [heroin] leans back and drops and then suddenly stops talking in a middle of a conversation and you look over and realize that they’re overdosing. Not like with fentanyl. I would say you notice it [a fentanyl overdose] as soon as they are done [injecting the fentanyl]. They don’t even have time to pull the needle out [of their body] and they’re on the ground.”

21. MDPH Chapter 55 – BMC Group Table of Approved Projects
Lead investigator
Co-Investigators
Working title – topic
Barocas
Bernson, Camona, Walley, Linas
Prevalence of opioid use disorder in the population – Capture/Recapture methodology
Larochelle
Bernson, Land, Stopka, Liebschutz, Walley
Medication for opioid use disorder following nonfatal opioid overdose and association with mortality
Walley
Bernson, LaRochelle, Green, Young, Land
Linking toxicology at death with prescription monitoring program records: implications for defining fentanyl and heroin-related deaths
Rose
Bernson, Chui, Land,Walley, LaRochelle, Stein, Stopka
Potentially Inappropriate Opioid Prescribing, Overdose, and Mortality in Massachusetts,
Stopka
Amaravdi, Kaplan,Hoh, Bernson,Chui, Land, Walley, LaRochelle, Rose
Opioid Overdose Deaths and Potentially Inappropriate Opioid Prescription Practices (PIP): A Spatial Epidemiological Approach
Morgan
Jaeger, Nguyen, Walley, Linas
Defining the cascade of care for substance use disorder detoxification in Massachusetts
Bagley
Larochelle, Walley, Hadland, Bernson, Land, Xuan, Samet
Time to treatment or overdose among emerging adults presenting or NFOD- Characteristics of emerging adults who overdose
Hadland
Larochelle, Walley, Bagley, Samet
Receipt of Pharmacotherapy among Adolescents and Young Adults with Opioid Use Disorder and its Impact on Fatal and Non-Fatal Overdose
Park
Larochelle, Walley, Saitz
Prescribing of benzodiazepines and stimulants among people with OUD>>retention and overdose
Larochelle, Babakhanlou-Chase, Land, Bernson
Factors Associated with Overdose Death Among Inpatient Detoxification Patients
Kimmel
Linas, Larochelle, Walley
Effect of treatment for opioid use disorder on opioid-related death among patients with intravenous drug associated endocarditis
Green, Stopka, LaRochelle, Ruiz
Community distribution of naloxone kits and naloxone rescues
Lunze and Ventura
Larochelle, Walley
Mandated treatment of persons with substance use disorders in Massachusetts: Cohort description and correlates

22. Self-protective measures often employed
Naloxone reverses overdoses involving IMF; multiple doses often required
“So he put half [one dose] up one nose [nostril] and half [one dose] up the other nose, like they trained us to do, and she didn’t come to. So he put water on her face and kind of slapped her, which doesn’t really make you come to [regain consciousness]. It doesn’t. So he pulled out another thing of Narcan [brand of naloxone] and he put half of it [another dose] up one nose and then she came to…She just didn’t remember anything. She said, ‘What happened? I remember washing my hands and, like, what happened?’ We said, ‘You just overdosed in this room!’ So yeah, it was wicked scary.”
Self-protective measures often employed
“Like I will do a very, very, very little bit of fentanyl…and if I don’t feel it, I will do that little bit plus half. I’m just not going to throw the whole thing in the cooker and then do it, no way. I just know better.”
Co-use of opioids and benzodiazepines
“My daughter’s mother had benzos. And when she did one bag of heroin she already had done four or five Klonopin [brand of clonazepam] and she just died. That was it. She went into a coma for the night and she was dead in the morning.”

23. A comprehensive public health response to address overdoses related to IMF
Fentanyl should be included on standard toxicology screens
Adapt existing harm reduction strategies, such as direct observation of anyone using illicit opioids, ensuring bystanders are equipped with naloxone
Enhanced access and linkage to medication for opioid use disorders

24. Demographics of cohort of opioid-related deaths
Analytic Cohort, opioid deaths with tox, n=2,916
All opioid-related deaths,
n=5,170
Age, mean, median
39.4 (38)
39.9 (39)
Gender
Male
73%
71%
Female
27%
29%
Race
White
87%
88%
Black
4.1%
4.0%
Asian/PI
0.4%
Hispanic
7.7%
7.1%
American Indian/Other
0.8%
0.9%