1. Karl Williams, MD, MPH Medical Examiner Allegheny County

2. The Overdose Problem in Allegheny County 2008 - 2011 Allegheny County Overdose Prevention Coalition July 31, 2012 Karl E. Williams, MD, MPH Chief Medical Examiner Allegheny County

3. National Statistics

4. Scope of the National Problem In the United States in 2007, unintentional poisonings were the second leading cause of injury death (after motor-vehicle crashes) Approximately 93% of all unintentional poisoning deaths were caused by drug poisoning In Florida, the nonsuicidal poisoning death rate increased 325% (1990 - 2001) Recent trends in Florida (2003 – 2009) – The number of annual deaths in which medical examiner testing showed lethal concentrations of one or more drugs increased 61.0% – The greatest increase was observed in the death rate from oxycodone (264.6%), followed by alprazolam (233.8%) and methadone (79.2%).

5. Florida Overdose Data – 2003 - 2009

6. ACOME Drug Deaths as % of Morgue Cases

7. ACOME Drug Deaths as % of Accidental Deaths

8. ACOME Drug Deaths by Age Group

10. ACOME Drug Deaths by Race/Sex

12. Figure 2. Number of drugs listed on death certificates, unintentional poisonings, Allegheny County, 2008-2010

13. ACOME Drug Deaths Total Single or Combined

14. ACOME Accidental Overdose Cases

18. Death Certification Process - OD Full Autopsy Submit toxicology specimens – Blood – heart and femoral – Urine – Eye fluid – Bile Determine active drugs found in various specimens Certify death as due to – Single drugeg. Cocaine – Multidrug toxicity

19. Method problems There is no universally accepted standard for death certification – No accepted postmortem interpretive levels – No true science to multidrug intoxication – Issue of post-mortem re-distribution – No “SOP” dictating how to evaluate the significance of different drugs in a mixture Deaths can also be certified as Undetermined – Can significantly effect Suicide rates Detection limits decrease with every passing year – mg/ml to mcg/ml to nanogram/ml

20. Method problems – Heroin v. Morphine Heroin undergoes a rapid breakdown to 6-MAM (6 monoacetylmorphine) – 6-MAM found more frequently in either blood or urine than heroin – If found in any substrate we can know that heroin was ingested Since morphine has a considerably longer half-life it is commonly the only compound found

21. Metabolism of Heroin 6-MAMA t ½ = 9 mins. t½ = 39 mins. t½ = 4 to 6 hours

22. Reclassification Process Case by case review of secondary information – Evidence of drugs at the scene – stamp bags – Evidence of injection sites Recent Healed linear scars – “tracks” – History of prior abuse – NO evidence of pharmaceutical morphine If morphine is found and one of the above holds true death was reclassified as being due to heroin Compliments to Kristen Mertz, MD - GSPH

23. Heroin: bricks, bundles, stamp bags…

24. Paraphenalia

26. Special case of codeine Codeine also breaks down to morphine but can occur as an additive to heroin (t½ = 3-5h.) When codeine is consumed as the primary drug the ratio of codeine to morphine is predictable

27. Figure 3. Most common substances detected by toxicology, unintentional drug overdose deaths, Allegheny County, 2008-2010 *Cocaine metabolites include benzoylecgonine, ecgonine methyl ester, cocaethylene

28. Figure 1. Most common drugs listed on death certificates, unintentional drug overdose deaths, Allegheny County, 2008-2010

29. Summary Allegheny County still has a relatively “traditional” pattern of drugs of abuse – Predominance of heroin and cocaine – Early rise of more modern synthetics in comparison with other parts of the U.S. – Only now beginning to see penetrance of “designer drugs”, at least as contributing to overdose deaths Heroin incidence in Allegheny County has been underestimated by prior classification schemes

30. Acknowledgements Kristen Mertz, MD, MPH – Department of epidemiology/GSPH/University of Pittsburgh Patricia Rekiel – Computer Analyst, ACOME Jennifer Jennsen – Chief Toxicologist, ACOME