1. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 1 A Public Health Response to an Epidemic of Fatal Drug Overdoses in North Carolina Catherine (Kay) Sanford, MSPH Injury and Violence Prevention Branch Division of Public Health, NC-DHHS kay.sanford@ncmail.net 919.707.5434

2. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 2 NC’s Public Health Steps 1. CDC-NCIPC Injury Indicator Report 2. EIS Investigation – Fatal Poisonings in NC 3. Task Force on Unintentional Drug Overdoses 4. MMWR on Unintentional Drug Overdoses in 11 states 5. Task Force Recommendations 6. NC-DOJ/DHHS Leadership Committee on Drug Overdoses 7. Year 1: Surveillance and PMP Legislation

3. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 3 1. CDC-NCIPC Injury Indicator Report 1.NC Division of Public Health Injury and Violence Prevention Branch funded through CDC’s “Core Capacity” program in 2000. 2.In 2001-2002, NC Injury Program participated in first national Injury Indicator Report; approx. 20 states, using 1999 data.

4. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 4

5. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 5 Definition of Poisoning Damaging physiologic effects from exposure to –pharmaceuticals (prescribed and OTC) –illicit drugs (e.g., cocaine, heroin) –chemicals (e.g., pesticides) –heavy metals (e.g., mercury) –gases/vapors (e.g., carbon monoxide) –household substances (e.g, bleach, ammonia)

6. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 6 Accidental Drug Overdose - International Classification of Disease (ICD) Definition Unintentional (Accidental) Drug Overdose –Inaccurate prescription or administration of a drug/substance –Inappropriate consumption of a drug/substance

7. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 7 Adverse Effect from Drug- International Classification of Disease (ICD) Definition Adverse Effect(s) from a Drug –Appropriate prescription/administration of drug with the patient experiencing an adverse physiologic reaction to the drug/substance.

8. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 8 Comparing NC injury trends to that of the nation. Intentional and Unintentional Poisoning Crude Death Rates in the US and NC: 1997-2001 WISQARS:www.cdc.gov/ncipc/ 1-2004

9. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 9 NC Resident Deaths Due to Poisoning by Manner/Intent: 1997 – 2001

10. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 10 2. EIS Investigation – ? Epidemic of Fatal Poisonings in North Carolina 1.Mortality data showed clear evidence that increase in deaths was due to unintentional poisonings. 2.NC State Health Director requested an EIS investigation from CDC 3.June-July 2002: Review of 1,096 Medical Examiner cases in 3 weeks 4.Confirmation on Indicator Report findings

11. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 11 Case Definition: Underlying cause of death from Medical Examiner –Underlying cause was drug-related based on impression of ME on investigation report, and review by pathologists and toxicologists at OCME: autopsy, toxicology report, review of clinical and historical information. –M. E. concluded manner of death was accidental

12. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 12 Case Definition for Reviewing Medical Examiner Cases of Accidental Drug Overdose Deaths Initial Selection: all NC residents dying in NC between 1997 and 2001, inclusive, with an underlying cause of death due to unintentional drug-related poisoning (E850- E858; X40-X44) with a death certificate on file at the NC State Center for Health Statistics.

13. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 13 ME Chart Abstraction 1096316278190155157 ME Abstraction 83.081.087.481.2 84.0% of VS 1320390318234191187Vital Stats 97-0120012000199919981997

14. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 14 Deaths from Unintentional Drug Overdoses from NC ME Data (n=1,096) by Age and Sex : 1997-2001

15. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 15 Unintentional Drug Deaths by Race from Abstracted ME Records (N=1096) in NC: 1997-2001

16. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 16 Unintentional Drug Deaths by Sex from Abstracted ME Records (N=1096) in NC: 1997-2001 Males: N=749 68.3% Females: N=347 31.7%

17. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 17 Unintentional Drug Deaths by Sex and Year from Abstracted ME Records (N=1096) in NC: 1997-2001 Males: 66% increaseFemales: 210% increase Males: 66% increase Females: 210% increase

18. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 18

19. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 19 Treatment Provided Prior to Deaths from Unintentional Drug Overdoses from Medical Examiner Data in North Carolina: 1997-2001 DOA = dead on arrival ED = emergency department Rx = treatment (1,096 ME cases)

20. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 20 Unintentional Drug Deaths by Past Medical History from Abstracted ME Records (N=1096) in NC: 1997-2001 20.4%Mental Health 20.1%Chronic Pain 23.8%Alcohol Abuse/Alcoholism 53.8%Drug Abuse

21. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 21 Decedents’ Source of Drugs from NC Medical Examiner Records by Sex : 1997-2001

22. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 22 Deaths Resulting From a Single Drug by Type and Sex, NC Medical Examiner Records: 1997-2001

23. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 23 Unintentional Deaths from a Single Drug: Illicit Drugs, North Carolina, 1997-2001

24. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 24 Unintentional Deaths from a Single Drug: Licit Drugs North Carolina, 1997-2001

25. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 25 Unintentional Deaths from Multiple Drugs: North Carolina, 1997-2001 No. deaths = 316

26. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 26 300% 729% 93% % change from 97 to 01 96 51 109 Number Change 88.1%12832All Rx Narcotics 46.7%587Methadone -----226117All Poisoning deaths % of overall increase 20011997 Deaths Resulting From a Single Drug (n=780): Change from 1997 to 2001

27. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 27 Why Methadone? Relatively effective AND cheap analgesic; Reluctance of some MD’s to prescribe other synthetic opioids (e.g., oxycodone); Relatively few side effects; no euphoria - The Catch 22 Very long half-life; Idiosyncratic metabolism; requires careful follow-up first couple of weeks.

28. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 28 The Source of the Methadone? Probably not the OTP clinics-diversion not thought to be prevalent in NC; Likely diversion from prescriptions for abuse - recreation or to compensate for no heroin; Likely misuse for pain management.

29. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 29 3. Creation of Task Force on Unintentional Drug Overdoses Created by Secretary of NC-DHHS, Nov. 2002 Mission: study epidemic and develop recommendations to identify, reduce and ultimately prevent unintentional deaths from the use of illicit and licit drugs.

30. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 30 Medical Practice Pharmacy Co-chaired by State Epidemiologist and Ass’t Director SBI Substance Abuse Services Medical Examiners Toxicology State and Federal Law Enforcement Epidemiologic Surveillance Public Health Injury Prevention Specialists Law and Criminal Justice North Carolina Task Force to Prevent Deaths from Unintentional Drug Overdoses Mental Health

31. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 31 Results of Task Force to Prevent Deaths from Unintentional Drug Overdoses Met for 15 months. Report sent to DHHS and DOJ, April 2004. Findings described an increasing epidemic of deaths from unintentional drug overdoses in NC. 48 Recommendations to prevent or mitigate deaths: –State infrastructure to focus on prevention; surveillance, law enforcement, legislation, education for professionals, education for public, and clinical intervention.

32. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 32 Three Dimensional Haddon Matrix Adapted from Runyan, CW. Injury Prevention, 1998(4), 302-307

33. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 33 4. MMWR on Unintentional Drug Overdoses in 11 states 1.Concomitant research within the state and with other states on increases in unintentional drug- related deaths. 2.Findings continued to support increasing deaths. 3. Published MMWR: March 26, 2004 (vol.53#11).

34. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 34 5. Task Force Recommendations Submitted to Secretary of NC-DHHS and Attorney General of NC-DOJ, April 2004. 48 recommendations: no defeats; never more than one “no” vote; primary objections from pharmacy representatives. Harm Reduction could not be included due to funding constraints.

35. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 35 NC Drug Task Force Recommendations 1.LEADERSHIP recommendations create a joint DHHS and DOJ leadership structure for oversight of all surveillance, intervention and enforcement activities related to preventing unintentional drug overdoses.

36. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 36 NC Drug Task Force Recommendations 2.SURVEILLANCE recommendations compile and monitor data relevant to unintentional overdoses that are provided to the DHHS/DOJ Leadership Committee at least four times a year.

37. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 37 NC Drug Task Force Recommendations 3.LAW ENFORCEMENT recommendations provide infrastructure to prevent illegal distribution and use of controlled medications.

38. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 38 NC Drug Task Force Recommendations 4.LEGISLATIVE INITIATIVE recommendations create requirements and regulations necessary to implement surveillance activities, create fines to help finance the system and improve access to treatment services.

39. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 39 NC Drug Task Force Recommendations 5.EDUCATIONAL INTERVENTIONS – GENERAL PUBLIC recommendations to raise public awareness about the magnitude, risks and signs of unintentional overdose, preventive behaviors and precautions, and available emergency treatment and law enforcement resources.

40. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 40 NC Drug Task Force Recommendations 6.EDUCATIONAL INTERVENTIONS – PROFESSIONALS recommendations to raise professional awareness about the magnitude, risks and signs of unintentional overdose and create practice guidelines and educational and credentialling requirements for prevention, treatment and enforcement activities.

41. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 41 NC Drug Task Force Recommendations 7.CLINICAL INTERVENTIONS - Recommendations to expand forgery notification systems, improve emergency provider preparedness, increase resources for recovering addicts, and broaden the evidence base for implementing new, effective out-patient and in-patient treatment programs.

42. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 42 6. NC-DOJ/DHHS Leadership Committee on Drug Overdoses Recommendations premised on a state infra-structure to focus on implementing recommendations. MOU required between NC-DOJ and DHHS, and signed August 2004. Committee convened October 2004; meets quarterly. Representation from Law Enforcement; Mental Health, Public Health, Clinical Practice, Pharmacy Practice with IVPB facilitator. Focus for 2005: surveillance and enabling legislation for a controlled substance reporting system

43. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 43 7. Year 1 Leadership Committee Priorities: Surveillance and PMP Legislation Injury surveillance from death certificates and hospital discharge data on drug-related events; on-going. New data available from Poison Control Center and Emergency Department databases. Enabling legislation required for monitoring prescriptions of controlled substances.

44. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 44 NC Resident Deaths Due to Poisoning by Manner/Intent: 1997 – 2004 SURVEILLANCE

45. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 45 Naming the PMP A controlled substance reporting (CSR) System is a system into which prescription data for designated schedules of controlled substances are reported by dispensers to a central location where the information is entered into an electronic database. North Carolina would report Schedules II-V prescriptions dispensed on an out-patient basis. LEGISLATION

46. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 46 Being Politically Savvy Established leadership authority. Reviewed the history of past failures. Identified stakeholders. Identified credible spokespersons. Identified the opposition. Identified House and Senate sponsors. LEGISLATION

47. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 47 What did we do differently? Re-cast the CSR System as a public health initiative, but … Agreed to have legislation submitted as a revision of the Controlled Substances Law. Worked through the NC-DHHS legislative liaison and legal counsel in DPH. Included legislation as a special amendment to the state budget. LEGISLATION

48. NC DHHS Injury and Violence Prevention Branch, 10/27/2005 48 Next Steps Have legislative rules adopted from the Mental Health Commission. Apply for implementation funding from national sources. Establish a CSR System Advisory Board. Design the actual database. Continue the collaboration between DMH, DPH and DOJ in North Carolina.