1. Surveillance of Drug Use and Overdose – An Overview 2013 CSTE Preconference Workshop Brad Whorton Jim Davis Michael Landen New Mexico Department of Health

2. Categories of Indicators Overdose death Overdose hospitalization – Neonatal abstinence syndrome Overdose emergency department visits Prescription opioid sales Controlled substance prescribing Drug use prevalence

3. Overdose Death

4. Rates are age-adjusted per 100,000 to the standard 2000 U.S. population Source: Bureau of Vital Records and Health Statistics, New Mexico Department of Health

5. Methods Used NM vital records multiple cause of death data. New Mexico resident deaths. Total drug overdose death underlying cause of death code (X40-X44, X60-X64, X85, Y10-Y14). Heroin overdose death any multiple cause of death field was equal to T40.1 AND the underlying cause of death code was defined as a total drug overdose death (X40-X44, X60-X64, X85, Y10- Y14). Rates were age-adjusted to the 2000 standard U.S. population.

6. Rates are age-adjusted per 100,000 to the standard 2000 U.S. population Source: Bureau of Vital Records and Health Statistics, New Mexico Department of Health

7. Methods Used NM vital records multiple cause of death data. New Mexico resident deaths. Prescription Opioid overdose death any multiple cause of death field was equal to T40.2 to T40.4 AND the underlying cause of death code was defined as a drug overdose death (X40-X44, X60-X64, X85, Y10-Y14). This definition is based on methods from “Vital Signs: Overdoses of prescription opioid pain relievers—United States, 1999-2008,” MMWR, Nov 4, 2011, 60(43):1487-1492. Rates were age-adjusted to the 2000 standard U.S. population.

8. Issue  Prescription opium (T40.0) and Other and unspecified narcotics (T40.6) are excluded from the definition.

9. Rates are age-adjusted per 100,000 to the standard 2000 U.S. population Source: Bureau of Vital Records and Health Statistics, New Mexico Department of Health

10. Methods  Used NM vital records multiple cause of death data.  New Mexico resident deaths.  Sedative-Hypnotic overdose death  any multiple cause of death field was equal to T42.3, T42.4, T42.6, or T42.7  AND the underlying cause of death code was defined as a total drug overdose death (X40-X44, X60-X64, X85, Y10-Y14).  Rates were age-adjusted to the 2000 standard U.S. population.

11. Issue  Rate may also include deaths due to other and unspecified antiepileptic drugs.

12. Rates are age-adjusted per 100,000 to the standard 2000 U.S. population Source: Bureau of Vital Records and Health Statistics, New Mexico Department of Health

13. Methods Used NM vital records multiple cause of death data. New Mexico resident deaths. Unspecified overdose death any multiple cause of death field was equal to T50.9 and there were not any multiple cause fields with values between T36 and T50.8 AND the underlying cause of death code was defined as a total drug overdose death (X40-X44, X60-X64, X85, Y10-Y14). Rates were age-adjusted to the 2000 standard U.S. population.

14. Source: New Mexico Office of the Medical Investigator

15. Issues Rates calculated using vital records data may differ from those based on medical investigator data due to: different coding systems. different jurisdictions/populations (Medical Investigator data may not include out-of-state resident deaths or toxicology/autopsy results of deaths on tribal or federal lands). The greater the unspecified category, the more difficult it is to assess specific drug overdose death rates. Changes with changes of death certifiers Changes with changes to toxicology panels

16. Overdose Hospitalization

17. Data include hospital discharges primary diagnosis) from in-state, non-federal hospitals (IHS not included). SOURCE: New Mexico Department of Health, Hospital Inpatient Discharge Data

18. Methods Used the primary diagnosis for drug overdose (ICD-9 codes E850-E858, E950-E950.5, E962, E980-E980.5) in the state’s Hospital Inpatient Discharge Database (HIDD). New Mexico resident hospitalizations. Rates were age-adjusted to the 2000 standard U.S. population.

19. HIDD only contains discharges from non-federal hospitals. Indian Health Service (IHS) and Veterans Administration (VA) facilities are not included in the data. HIDD does not contain hospital discharges to New Mexico residents discharged from out of state hospitals. Overdoses that result in only an ED visit without a hospital admission are not included in the HIDD. Admission criteria may differ among hospitals. Issues

20. Neonatal Abstinence Syndrome

21. Data include hospital discharges (all diagnoses) from in-state, non-federal hospitals (IHS not included) SOURCE: New Mexico Department of Health, Hospital Inpatient Discharge Data and Vital Records data

22. Methods Used all diagnoses for neonatal abstinence syndrome (ICD- 9 code 779.5) for New Mexico residents in the state’s Hospital Inpatient Discharge Database (HIDD) for the numerator. Used NM vital records to generate the number of live births to New Mexico residents for the denominator. Calculated the rate per 1,000 live births.

23. Issues HIDD only contains discharges from non-federal hospitals. Indian Health Service (IHS) and Veterans Administration (VA) facilities are not included in the data which may result in an undercount. HIDD does not contain hospital discharges to New Mexico residents discharged from out of state hospitals. The diagnosis of neonatal abstinence syndrome will vary by hospital and physician.

24. Overdose Emergency Department Visits

25. Methods Used the primary diagnosis for drug overdose (ICD-9 codes E850-E858, E950-E950.5, E962, E980-E980.5) in the state’s Emergency Department Database. New Mexico resident emergency department visits. Rates were age-adjusted to the 2000 standard U.S. population.

26. Only includes emergency department visits from non- federal hospitals. Indian Health Service (IHS) and Veterans Administration (VA) facilities are not included in the data. Emergency department visits among New Mexico residents discharged from out of state emergency departments are not included. E-coding can vary by hospital. Issues

27. Prescription Opioid Sales

28. Sales ratios were calculated based on sales by weight (kilogram) per 10,000 population Source: ARCOS (Automation of Reports and Consolidated order Systems) database, Drug Enforcement Administration

29. Methods Used ARCOS DEA data to generate sales by weight (in grams) for prescription opioids in the database. Grams by weight was converted to kilograms then divided by the state population per 10,000 persons. Calculation and presentation of sales ratios based on methodology from “Vital Signs: Overdoses of prescription opioid pain relievers—United States, 1999-2008,” MMWR, Nov 4, 2011, 60(43):1487-1492.

30. Issues ARCOS sales data are provided for individual drugs by weight (in grams). Prescription opioids must be sorted out and summed. Schedule II and Schedule III opioids included in the database. Sub-state data are limited to three-digit zip codes. U.S. Census population estimates for zip codes are only generated for decennial census years. Sales comparisons between individual opioids may be problematic as some opioids (e.g., Methadone) are not easily converted to MMEs (Morphine milligram equivalents) without specific dosage information, which is not known.

31. Controlled Substance Prescribing

32. Opioids Dispensed Source: New Mexico Board of Pharmacy, Pharmacy Monitoring Program, 2012

33. Sedative-Hypnotics Dispensed Source: New Mexico Board of Pharmacy, Pharmacy Monitoring Program

34. Definitions Opioids – All opioid drugs, including morphine, methadone, fentanyl, buprenorphine, etc. Sedative-Hypnotics – Benzodiazepines (e.g. Valium) and Benzo-like sleep aids (e.g. Ambien) MME – Morphine milligram equivalents derived from an equivalence factor VME – Valium milligram equivalents derived from an equivalence factor

35. Methods 1.Create translations from National Drug Code (NDC) to drug class, strength and morphine/valium equivalents (resources are available). 2.Apply the conversion factors to the relevant time period of prescription data:  MME = MME_Factor(NDC)*strength(NDC)*quantity 3.Aggregate by year and month.

36. Issues Access to PMP data Statutes and regulations Technical issues (location, updates, security) PMP is a large, complex database Critical tables are: prescription, practitioner, patient, pharmacy and drug (NDC). Requires some processing to make datasets suitable for analysis.

37. Dangerous Prescribing Criteria High Dose 32.7% Source: New Mexico Board of Pharmacy, Pharmacy Monitoring Program

38. Definitions Prescriber criteria based on prescriptions filled by patients over 12 months. Minimum of 10 patients and 100 fills per prescriber. Duo – At least 50% of patient-months with opioid fills also had benzodiazepine fills. Trio – at least 40 patient-months with fills for opioids, benzodiazepines and carisoprodol. High dose – at least 20% of opioid prescriptions filled were over 200 MME/day. Multiple – more than one of the above.

39. Methods Aggregation in 3 steps: Prescriber, patient & calendar month Prescriber, patient (counting months by category) Prescriber (counting patient-months) Patient defined in terms of name and DOB.

40. Suboxone Prescribing New Mexico, 2011-2012

41. Methods Suboxone patient – a patient who has filled 2 or more prescriptions for suboxone; individual defined by name & dob. Suboxone prescriber – a prescriber who has prescribed suboxone to 15 or more patients; duplicate prescriber records combined. Region – NM health region as determined by the zip code of the patient or prescriber. Data for July 2011 – June 2012.

42. Issues Suboxone is used to treat pain in addition to its use in addiction treatment – not a pure measure of addiction services. Zip code to county works fairly well in NM; it may not in other states. Suboxone prescribers are more likely to have multiple records in the practitioner file, requiring combining the records to avoid over-counting.

43. Drug Use Prevalence

44. * State added question Source: New Mexico Youth Risk and Resiliency Survey, New Mexico Department of Health

46. Methods The NM Youth Risk and Resiliency Survey (YRRS) is a survey measuring the prevalence of risk behaviors and resiliency (protective) factors among public high school (grades 9–12) and middle school (grades 6-8) students. The YRRS is a part of the Youth Risk Behavior Surveillance System (YRBS), designed and implemented nationally by CDC, and implemented in most states by state Health and/or Education agencies. The YRRS is administered anonymously with a paper and pencil survey instrument, in the classroom. Sample size = 5,875. Example of a current prevalence question: “During the past 30 days, how many times have you used heroin (also called smack, junk, or China White)?” Example of a lifetime prevalence question: “During your life, how many times have you used any form of cocaine, including powder, crack, or freebase?”

47. Issues 80 of New Mexico’s 89 public school districts participated in the YRRS in 2011. The 2011 high school response rate was 63%. Only New Mexico public school students were surveyed. Private schools and Bureau of Indian Education (BIE) schools were not included in the sampling frame. Due to methodological differences, particularly in the mode of survey, YRRS prevalence rates may differ from those of other surveys (e.g., NSDUH).

48. Source: National Survey of Drug Use and Health, Substance Abuse and Mental Health Services Administration, 2012

50. Methods The NSDUH is an annual survey of the civilian, non-institutionalized population aged 12 years and older. In 2010-2011, NSDUH collected data from 137,913 respondents. The national sample was interviewed using a computer-assisted interviewing (CAI) method. The survey used a combination of computer-assisted personal interviewing (CAPI) conducted by an interviewer and audio computer-assisted self-interviewing (ACASI). Use of ACASI is designed to provide the respondent with a highly private and confidential means of responding to questions and increases the level of honest reporting of illicit drug use and other sensitive behaviors. 2011 NSDUH employed a 50-State design with an independent, multistage area probability sample for each of the 50 States and the District of Columbia.

51. The screening response rate (SRR) for 2010-2011 combined averaged 87.7 percent, and the interview response rate (IRR) averaged 74.5 percent, for an overall response rate (ORR) of 65.3 percent. Due to methodological differences, particularly in mode of survey, results can differ compared with similar indicators in the YRRS. Issues

52. Recommendations In addition to the work going on with standardizing overdose death surveillance, consider standardizing surveillance for other measures relevant to drug use and overdose Standardize definition of sedative-hypnotic

54. Opioid Conversion Factors Generic name MME Factor Generic name MME Factor BUPRENORPHINE10MORPHINE1 BUTORPHANOL7NALBUPHINE1 CODEINE0.15OPIUM1 DIHYDROCODEINE0.25OXYCODONE1.5 FENTANYL100OXYMORPHONE3 HYDROCODONE1PENTAZOCINE0.37 HYDROMORPHONE4PROPOXYPHENE0.23 LEVORPHANOL11TAPENTADOL1 MEPERIDINE0.1TRAMADOL0.1 METHADONE3

55. Sedative-Hypnotic Factors Generic NameVME FactorGeneric NameVME Factor Alprazolam20Halazepam0.5 Chlordiazepoxide0.4Lorazepam10 Clobazam0.5Midazolam1 Clonazepam20Oxazepam0.5 Clorazepate0.667Prazepam0.667 Diazepam1Quazepam0.5 Estazolam5Temazepam0.5 Flurazepam0.4Triazolam20 Eszopiclone0.333Zolpidem0.5 Zaleplon0.5Zopiclone0.667