1. The Office of the Chief Medical Examiner, Virginia Department of Health

2. Deaths from Heroin and Prescription Opiates in Virginia: An Overview William T. Gormley, MD, PhD, Chief Medical Examiner Rosie Hobron, MPH, Forensic Epidemiologist
Data Sources: Office of the Chief Medical Examiner, Virginia Medical Examiner Data System (VMEDS)

3. Office of the Chief Medical Examiner
Code of Virginia § Investigation of deaths: obtaining consent to removal of organs, etc.; fees

4. Deaths from Heroin and Prescription Opiates

7. Heroin and Prescription Opiates
Heroin under-represented
Heroin is Morphine Pro-drug
Diagnosis of Heroin COD
6-Acetyl Morphine
Circumstances
Opiates – prescription vs. illicit
Medical Records
Scene and circumstances

8. Heroin
3,6 Diacetyl Morphine
6-Acetyl Morphine
T ½
2-3 min
Morphine
T ½
< 5 min
T ½
2-3 hours
Inactive
Metabolites

9. Definition
Half Life
The length of time it takes the concentration of a drug in the blood to decrease to ½ of its current value

10. Heroin Diacetyl (3,6) Morphine T ½ 2-3 min
Inactive but rapidly converted to morphine
Liver – glucuronide – kidney
RUSH occurs while conversion to 6-MAM and morphine in brain

11. 6-acetyl morphine Monoacetyl morphine T ½ less than 5 min
Psychoactive metabolite, somewhat more potent than morphine
May be responsible for RUSH
Greater histamine release than morphine when IV

12. Morphine
T ½ 2 – 3 hours
Liver – glucuronide - kidney

13. Heroin
3,6 Diacetyl Morphine
6-Acetyl Morphine
T ½
2-3 min
Morphine
T ½
< 5 min
T ½
2-3 hours
Inactive
Metabolites

14. Heroin > 20% average annual increase over decade
35% increase from 2011 to 2012
58% increase from 2012 to 2013

16. Opiates – Prescription vs. illicit

17. Prescription Opiate Drugs
4 % average annual increase over 7 years
13% increase from 2012 to 2013
9% projected increase from 2013 to 2014

18. Heroin and Prescription Opioids

19. Heroin and Prescription Opiate Drugs
From , nearly 70% of all drug/poison deaths were attributed to opiates.

21. Surveillance Roles Situational Awareness
Monitor death incidence as close to real time as possible.
Forecast and warn public.
Prevention
Identify strategies.
Evaluate and document result of strategy implementation.

22. Surveillance Data OCME Death data delayed by 3 to 6 months
Other data streams include:
Hospital and ER admissions – VDH
Law enforcement drug seizures – DFS
Law enforcement intelligence – i.e. Fusion
Prescription Monitoring Program (PMP)

23. Summary Heroin under-represented Heroin is Morphine Pre-drug
Diagnosis of Heroin COD
6-Acetyl Morphine
Circumstances
Opiates – prescription vs. illicit
Medical Records
Scene and circumstances
General increase in deaths from both over the last decade.
Heroin approximately 20% per year, 35% in 2012, >50% in 2013
Prescription opiates approximately 10% per year, 15% in 2012
Surveillance
Situational Awareness
Identify Prevention Strategies
Evaluate Prevention Strategies