1. The Grand Unifying Theory of Poisoning/Overdose Surveillance A Collaborative Effort June 9, 2013

2. Motor Vehicle Traffic, Poisoning, and Drug Poisoning Death Rates US 1980-2010 NCHS Data Brief, December, 2011, Updated with 2009 and 2010 mortality data

3. Opioid Analgesics: The National Picture Fastest growing drug problem in United States Enough prescription painkillers prescribed in 2010 to medicate every American adult around- the-clock for a month ~12 million Americans report misuse of opioid analgesics within past year (2010) >16,000 overdose deaths from opioid analgesics (2010) Considered an “epidemic”

4. Background & History

5. Safe States Poisoning Workgroup- 2008 Safe States formation of Injury Surveillance Workgroup (ISW-7) Publication of ISW7- May 2012 CDC/Safe States/CSTE conferences 2012 CSTE Drug Overdose- –Willing and wanting to test ISW7 indicators –Providing organizational base for effort SQI Year 2 focus on poisoning Real partnership with Safe States – liaison/driving force Scott Proescholdbell

6. Why CSTE Overdose subcommittee choose this project Increased attention by States to report and track drug overdose Lack of consistent definitions and indicator Variations across States and local level Recognizing that lack of detail on death certificates underestimates deaths for specific drugs Concern about shifting from opioid analgesics to heroin → accurate classification of opiates critical

7. Timeline 2012-2013

8. Timeline August- Organizational Call Creation of Poisoning Surveillance Workgroup Fall 2012- Creation of tables shells and Levels I-IV (basic to complex) Winter- submission of data by volunteer states and proposal to present data Spring- Data results & write up of methods and process for Special Emphasis Report Spring- April CDC mtg on poisoning for Core states

9. Next Steps

10. June- Presentations (Safe States & CSTE) July- development of Special Emphasis Report and pilot testing Transition from mortality to morbidity (SQI protocol) Additional testing of codes, development of potential indicators and position statements

11. Introduction to Mortality Surveillance: Levels 1-3 Daniella Bradley O’Brien

12. Outline Definition of terms –What is a drug poisoning (overdose) death? –What is an ICD Code? What ICD-10 codes are used? Intent Underlying/Multiple Cause of Death Surveillance levels 1-4 How to surveil drug poisoning deaths

13. Definition of Terms

14. International Classification of Diseases-10 th classification (ICD-10) Standard diagnostic tool for epidemiology, health management and clinical purposes Monitors the incidence and prevalence of diseases and other health problems Defines the universe of diseases, disorders, injuries and other related health conditions. It allows for: –sharing and comparing health information between hospitals, regions, settings and countries; and –data comparisons in the same location across different time periods. Does not always identify specific drugs causing death

15. External Cause of Injury Mortality Matrix

16. Mechanism of Death Intent of Death (Based ICD-10) UnintentionalSuicideHomicideUndetermined Legal Intervention/war PoisoningX40-X49X60-X69 X85-X90, U01.6-.7 Y10-Y19Y35.2

17. Drug TypeUnintentionalSuicideUndeterminedHomicide Nonopioid analgesics, antipyretics and anti- rheumatics X40X60Y10 X85 Sedative-hypnotic, psychotropic X41X61Y11 Narcotics and psychodysleptics (hallucinogens), NOS X42X62Y12 Other drugs acting on CNSX43X63Y13 Other and unspecified drugs X44X64Y14 Underlying ICD-10 Drug Poisoning Codes

18. Medical Examiner/Coroner: Determining cause and manner of death Death scene investigation Autopsy Toxicology Determination of cause and manner of death Context Paraphernalia Pill bottles Witness accounts Physical findings Heart muscle (e.g. damaged by cocaine use) Asthma Drugs Active (capable of causing death) Synergistic Contributing Present, not active

19. CAUSE OF DEATH (See instructions and examples) Approximate interval: Onset to death 32. PART I. Enter the chain of events - - diseases, injuries, or complications - - that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE (Final disease or condition resulting in death) a. Acute intoxication Sequentially list conditions, if any, leading to the cause listed on line a. Enter the UNDERLYING CAUSE (disease or injury that initiated the events resulting in death) LAST Due to (or as a consequence of): Due to the combined effects of b. Heroin and Oxycodone Due to (or as a consequence of): c. Due to (or as a consequence of): d. PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in Part I. Asthma 33. WAS AN AUTOPSY PERFORMED? Yes No 34. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE THE CAUSE OF DEATH? Yes No 35. DID TOBACCO USE CONTRIBUTE TO DEATH? Yes Probably No Unknown 36. IF FEMALE: Not pregnant within past year Pregnant at time of death Not pregnant but pregnant within 42 days of death Not pregnant but pregnant 43 days to 1 year before death Unknown if pregnant within the past year 29. MANNER OF DEATH Natural Pending Accident Investigation Suicide Could not be Homicide Determined 38. DATE OF INJURY (Mo/Day/Yr)(Spell Month) 39. TIME OF INJURY 40. PLACE OF INJURY (e.g., Decedent’s home, construction site, restaurant, wooded area) 41. INJURY AT WORK? Yes No 42. LOCATION OF INJURY: State: City or Town: Street & Number: Apartment No. Zip Code: 43. DESCRIBE HOW INJURY OCCURRED Acute and Chronic Substance Abuse 44. IF TRANSPORTATION INJURY, SPECIFY Driver/Operator Passenger Pedestrian Other (Specify) To Be Completed By: MEDICAL CERTIFIER X Part II Other significant conditions contributing to death Part I Lines a-d Causes of death are entered sequentially starting with immediate cause and ending with the underlying cause. How injury occurred Generally determines external cause of death. Manner

20. Death Certificate Literals “Literals” are the exact text entered on the death certificate Specialized software reads the literals and automatically codes both underlying and multiple cause of death

21. Exact words from Part I, Part II, manner and how the injury occurred Mortality Medical Data System Automated coding of causes of death Death Certificate Cause of death Part 1 a. _Acute Intoxication b.Due to combined___ effects of heroin and oxycodone. _________________ d. _________________ Part 2 :Asthma Manner: Accident Describe how injury occurred: Acute and Chronic Substance Abuse Cause of death by ICD-10 codes UCOD: X42 MCOD: X42, T40.1, T40.2,

22. CSTE Validation of ISW-7: Methods 4 levels –Level 1: Basic –Level 2: Multiple Cause –Level 3: Cross-Check –Level 4: Multi-stage Year 2010 Residents of each state that died in state 11 states/jurisdictions

23. Drug Poisoning Mortality Surveillance “Levels 1-4” Level 4: Multi-Stage Toxicology and Literals Level 3: Cross-Check Literal text from death certificate Level 2: Multiple Cause Level 1: Basic Underlying cause of death file

24. Level 1: Basic Analysis Objective Level 4: Multi-Stage Toxicology and Literals Level 3: Cross-Check Literal text from death certificate Level 2: Multiple cause of death file Level 1: Underlying cause with associated demographics

25. Level 1: Basic Analysis *Note: To obtain Death Certificate contact your city/state’s Office of Vital Statistics or agency equivalent responsible for the reporting, processing, and analyzing all vital events (births, deaths, etc.) Required Resource: Death Certificate* Obtain Underlying Codes Use Underlying Codes: X40-X44, X60-X64, X85, Y10-Y14, Y40-Y59, [F11-F16] (.0), F19.0 Tabulate results for Level 1

26. Level 1: Basic Analysis DemographicsX40X41X42X43X44 X40-X44 Total N%N%N%N%N%N% Total 87100% 87 100% Gender Male 54 62% 54 62% Female 33 38% 33 38% Race/Ethnicity Black Non-Hispanic 27 31% 27 31% White Non-Hispanic 29 33% 29 33% Hispanic 28 32% 28 32% Asian/Pacific Islander 1 1% 1 American Indian/ Alaskan Native 1 1% 1 All Other 1 1% 1 Age Group 0-14 1 1% 1 15-24 10 11% 10 11% 25-34 15 17% 15 17% 35-44 20 23% 20 23% 45-54 18 21% 18 21% 55-64 10 11% 10 11% 65-84 6 7% 6 85+ 4 5% 4

27. Level 1: Summary Report on poisoning by intent Provide demographic profile of the decedents –Age –Gender –Race/Ethnicity –Residential information available but not collected/tested as part of CSTE validation of ISW-7

28. Level 2: Multiple Cause Objective Level 4: Multi-Stage Toxicology and Literals Level 3: Cross-Check Literal text from death certificate Level 2: Drug Specificity (T-Codes) Level 1: Underlying cause with associated demographics

29. T-codes Are multiple cause codes Identify specific drug or substance For poisoning and toxic effects in ICD-10 these are T36-T65

30. Multiple Cause T-Codes by Drug Type Example drugsDrug categoryICD-10 code “Morphine” “Oxycodone” “Hydrocodone” Natural and semi-synthetic opioid analgesics (aka “Other opioids”) T40.2 “Methadone”MethadoneT40.3 “Fentanyl” “Propoxyphene” “Meperidine” Synthetic opioid analgesics, excluding methadone (aka “Other synthetic narcotics”) T40.4 “Opiates” “Opioid” “Narcotics” Other and unspecified narcoticsT40.6 “Cocaine”CocaineT40.5 “Heroin”HeroinT40.1 “Alprazolam”BenzodiazepinesT42.4 “Methamphetamine”MethamphetamineT43.6 “Drugs” “Polypharmacy” Other and unspecified drug(s)T50.9 Opioid analgesics

31. Level 2: Multiple Cause Analysis Required Resource: Death Certificate* Obtain Multiple Cause Codes: 1. Underlying Cause Codes 2. Contributing Cause Codes Tabulate results for Level 2 Use Multiple Cause Codes: X40-X44, X60-X64, X85, Y10-Y14, Y40-Y59, [F11-F16] (.0), F19.0, T36-T50.9

32. Level 2: Multiple Cause Codes X40X41X42X43X44 Total X40-X44 N%N%N%N%N%N% T42.4:Benzodiazepines10 9% 10 9% T40.1: Heroin20 18% 20 18% T40.2: Other opioids (Incl:Codeine, Oxycodone,Morphine)35 32% 35 32% T40.3 Methadone10 9% 10 9% T40.4:Other synthetic narcotics(Incl:Pethidine)1 1% 1 T40.5: Cocaine15 14% 15 14% T40.6:Other and unspecified narcotics7 6% 7 T50.9: Other and unspecified drugs, medicaments and biological substances 10 9% 10 9% T50.9: Other and unspecified drugs, medicaments and biological substances **Only T50.9 listed, no other T-codes (between T30.0 and T50.8) listed** 2 2% 2 * This row includes any mention of T50.9, where it can be listed alone or as one of several T-codes listed. ** This row includes only occurrences where T50.9 is the only T-code listed (between T36.0 and T-50.8). This is a subset of the Any Mention of T50.9 row.

33. Level 2: Summary Report major categories of drug types by intent

34. Level 3: Cross-Check Objective Level 4: Multi-Stage Toxicology and Literals Level 3: Literal text from death certificate Level 2: Drug Specificity (T-Codes) Level 1: Underlying cause with associated demographics

35. Uses of literal text Identifying specific substances in “other specified” ICD-10 drug categories Monitoring increases in deaths associated with drug substances not specifically identified in ICD-10 Potential for use as a sentinel surveillance system for new drugs associated with deaths

36. Level 3: Cross-Check Analysis Required Resource: Death Certificate* Obtain Multiple Cause Codes: 1.Underlying Cause Codes 2. Contributing Cause Codes Tabulate results for Level 3 Cross-check Death Certificate Literals against Multiple Cause Codes Use Multiple Cause Codes: X40-X44, X60-X64, X85, Y10-Y14, Y40-Y59, [F11-F16] (.0), F19.0, T40.1,T40.2,T40.3,T40.4,T40.6,T43.6,T50.9

37. Level 3: Cross-Check Analysis Part 1aPart 1bPart 1cPart 2 Underlying Code Multiple/ Contributing Codes How Injury Occurred Acute Oxycodone Intoxication X42T40.2Ingested Medication

38. Level 3 Summary Specificity of literals – ex: T40.2 Oxycodone/Hydrocodone/Morphine Determine how literals are coded in your state/jurisdiction

39. Introduction to Level 4: Multistage Analysis Denise Paone

40. Drug overdose deaths – 4 “Levels” Level 4: Toxicology and Literals Level 3: Literal text from death certificate Level 2: Drug Specificity (T-Codes) Level 1: Underlying cause of death file

41. Definitions/Terms Toxicology –Collected and analyzed as part of death investigation –Not always available

42. Level 4: Multistage Analysis Objective & Methods Objective: –Compare toxicology results using ME findings, with ICD-10 codes and literals found on death certificates Methods: –Restricted T-Codes to cases involving opioids/unspecified

43. Level 4: Multistage Required Resource: Death Certificate* + Medical Examiner/Coroner files containing Toxicology Report Comparison of Death Certificate Multiple Cause Codes with confirmed Toxicology data Comparison of Death Certificate Literals with confirmed Toxicology data Comparison of Death Certificate Multiple Cause Codes, confirmed Toxicology data and Literals Tabulate results for Level 4 in table shell provided Obtain Multiple Cause Codes: 1. Underlying Cause Codes 2. Contributing Cause Codes Use Multiple Cause Codes: X40-X44, X60-X64, X85, Y10-Y14, Y40-Y59, [F11-F16] (.0), F19.0, T40.1,T40.2,T40.3,T40.4,T40.6,T43.6,T50.9

44. Level 4: Multistage Analysis Part 1a Part 1b Part 1cPart 2 Underlying Code Multiple/ Contributing Codes How Injury OccurredToxicology Acute intoxication by the combined effects of Oxycodone, Morphine, Diazepam, and Cocaine X42- T40.2 T50.9 Benzoylecgonine, Diazepam, Oxazepam, Oxycodone, Temazepam

45. Level 4 Summary Raises more questions than it answers?! Continue to refine this analysis

46. Acknowledgements CSTE Overdose sub-committee members Safe States Members CDC Staff NYC DOHMH