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The Emerging Illicit Fentanyl Overdose Epidemic: Perspectives from the National and State Levels

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  1. 1. The Emerging Illicit Fentanyl Overdose Epidemic: Perspectives from the National and State Levels Presenters: • R. Matthew Gladden, PhD, Behavioral Scientist, PDO Surveillance and Epi Team, Division of Unintentional Injury Prevention, CDC • John Halpin, MD, MPH, Medical Officer, PDO Surveillance and Epi Team, Division of Unintentional Injury Prevention, CDC • Traci Green, PhD, MSC, Deputy Director, Boston Medical Center Injury Prevention Center, and Associate Professor of Emergency Medicine, Boston University Federal Track Moderator: Regina M. LaBelle, JD, Chief of Staff, White House Office of National Drug Control Policy, and Member, Rx Summit National Advisory Board
  2. 2. Learning Objectives 1. Explain the epidemiology of the rise in fentanyl overdoses in the United States. 2. Identify lessons learned during an epidemiologic investigation of a sharp increase in fentanyl overdoses in Ohio. 3. Describe one state’s experience with and responses to the fentanyl overdose epidemic.
  3. 3. Increases in Fentanyl-Involved Deaths in the US: 2013-2014 The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. R. Matt Gladden & John Halpin Division of Unintentional Injury Prevention National Center for Injury Prevention and Control Centers for Disease Control and Prevention
  4. 4. Fentanyl • Synthetic and short-acting opioid analgesic • 100X more potent than Morphine • 50X more potent than Heroin • Primary use is for managing acute or chronic pain associated with advanced cancer
  5. 5. Illicitly-Made Fentanyl (IMF) • Illicitly-made fentanyl and fentanyl analogs • Most recent increases in nonfatal and fatal fentanyl-involved overdoses linked to IMF • Often mixed with heroin or sold as heroin Algren D, Monteilh C, Rubin C, et al. Fentanyl-associated fatalities among illicit drug users in Wayne County, Michigan (July 2005-May 2006). Journal Of Medical Toxicology: Official Journal of the American College Of Medical Toxicology [serial online]. March 2013; 9(1):106-115. U. S. Department of Justice, Drug Enforcement Administration, DEA Investigative Reporting, January 2015
  6. 6. • Pharmaceutical fentanyl (from transdermal patches or lozenges) diverted at small levels • Latest overdose deaths are largely due to clandestinely- produced fentanyl March 18, 2015 April, 2015 DEA Nationwide Alert available at: http://www.dea.gov/divisions/hq/2015/hq031815.shtml National Heroin Threat Assessment Summary available at: http://www.dea.gov/divisions/hq/2015/hq031815.shtml
  7. 7. CDC Health Advisory on fentanyl available at: http://emergency.cdc.gov/han/han00384.asp October, 2015
  8. 8. Data Sources • National Forensic Laboratory Information System (NFLIS)  Drug Enforcement Administration, Office of Diversion Control  50 state systems and 101 local or municipal laboratories / laboratory systems  NFLIS reporting laboratories capture over 91% of the national drug caseload  924,120 distinct drug cases were submitted to state and local laboratories in 2014 • State medical examiner and coroner (ME/C) reports  Can identify fentanyl because ME/C reports are available earlier than national drug overdose statistics  Have to request for each state Information on NFLIS available at: https://www.nflis.deadiversion.usdoj.gov/DesktopModules/ReportDownloads/Reports/NFLIS2014AR.pdf
  9. 9. Death Certificate Data  Toxicology of overdose deaths cannot distinguish pharmaceutical fentanyl from illicitly-made fentanyl  Fentanyl grouped with other synthetic drugs such as tramadol in national reporting • The category excludes methadone  Not all jurisdictions test for fentanyl  State and local health departments explore using word searches to identify fentanyl deaths: http://www.cste.org/blogpost/1084057/211072/Epi- Tool-to-Analyze-Overdose-Death-Data  National, state and county level data available at: http://wonder.cdc.gov/mcd.html
  10. 10. Reported Fentanyl Law Enforcement Seizures Surged from 2013 to June 2015, Unpublished NFLIS data* 0 1000 2000 3000 4000 5000 6000 7000 Jan.-June 2012 July-Dec. 2012 Jan.-June 2013 July-Dec. 2013 Jan.-June 2014 July-Dec. 2014 Jan.-June 2015 NumberofReportedFentanylSeizures *NFLIS , Drug Enforcement Administration, Office of Diversion Control
  11. 11. More than 80% of 2014 Fentanyl Seizures Occurring in 10 States* *Data from NFLIS , Drug Enforcement Administration, Office of Diversion Control. More information can be found at CDC Health Advisory on Fentanyl available at: http://emergency.cdc.gov/han/han00384.asp
  12. 12. CDC Health Advisory on fentanyl available at: http://emergency.cdc.gov/han/han00384.asp
  13. 13. Fentanyl Seizures Related to Increases in Fentanyl-Involved Overdose Deaths in Multiple States 0 100 200 300 400 500 600 Ohio Maryland Florida NumberofFentanyl-involveddeaths 2013 2014 CDC Health Advisory on fentanyl available at: http://emergency.cdc.gov/han/han00384.asp
  14. 14. National Picture
  15. 15. Increases in Reported Synthetic Opioid Drug Seizures and Overdose Deaths Involving Synthetic Opioids from 2013 to 2014* *Data from NFLIS , Drug Enforcement Administration, Office of Diversion Control reported in the https://www.nflis.deadiversion.usdoj.gov/DesktopModules/ReportDownloads/Reports/NFLIS2014AR.pdf and https://www.nflis.deadiversion.usdoj.gov/DesktopModules/ReportDownloads/Reports/NFLIS-SR-Opioids-Rev.pdf. Data on other synthetic deaths extracted from CDC Wonder Multiple Cause of Death File: http://wonder.cdc.gov/mcd.html 0 1000 2000 3000 4000 5000 6000 7000 8000 9000 2010 2011 2012 2013 2014 Number # Reported Other Synthetic Opioid Seizures # of Other Synthetic Opioid-Involved Deaths (T40.4)
  16. 16. Increases in Reported Fentanyl Seizures is a Major Factor Driving Increases in Reported Opioid Synthetic Drug Seizures from 2013 to 2014* *Data from NFLIS , Drug Enforcement Administration, Office of Diversion Control reported in the https://www.nflis.deadiversion.usdoj.gov/DesktopModules/ReportDownloads/Reports/NFLIS2014AR.pdf and https://www.nflis.deadiversion.usdoj.gov/DesktopModules/ReportDownloads/Reports/NFLIS-SR-Opioids-Rev.pdf. 0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000 2010 2011 2012 2013 2014 Number Reported Fentanyl Seizures Reported Other Synthetic Opioid Seizures
  17. 17. States (n=37) with Rapid Increases in Fentanyl Seizure Rates from 2013-2014 Reported Increases in Other Synthetic Opioid Deaths from 2013-2014 0 1 2 3 4 5 6 7 -1 to 1 1 to 2.49 2.5 to 4.99 Greater than 5 ChangeinSynthetic-InvolvedOverdoseRate from2013-14per100,000Residents Change in Fentanyl Seizures Rate from 2013-14 per 100,000 residents 4 states5 states25 states 3 states *NFLIS , Drug Enforcement Administration, Office of Diversion Control
  18. 18. States (n=37) with Rapid Increases in Fentanyl Seizure Rates from 2013-2014 Reported Increases in Synthetic Deaths from 2013-2014 0 1 2 3 4 5 6 7 -1 to 1 1 to 2.49 2.5 to 4.99 Greater than 5 ChangeinSynthetic-InvolvedOverdoseRate from2013-14per100,000Residents Change in Fentanyl Seizures Rate from 2013-14 per 100,000 residents .9 - 2.3 per 100,00 .6 - 2.9 per 100,000 -.4 – 1.1 per 100,000 3.7 - 9.1 per 100,00 *NFLIS , Drug Enforcement Administration, Office of Diversion Control
  19. 19. Health Advisory Recommendations
  20. 20. Improve Detection Public Health Departments • Explore methods for rapidly identifying drug overdose outbreaks • Track fentanyl seizure information • Track decedent demographics and risk factors (e.g., drug type and route of administration) and geographic concentrations to inform overdose prevention efforts Law Enforcement • Rapid testing of evidence from drug overdose scenes • Collaborate with public health • Protection of first responders when handling fentanyl
  21. 21. Improve Detection: Medical Examiner Coroners Screen for fentanyl in suspected opioid overdose  Increase in fentanyl seizures  Increase in opioid-involved overdose fatalities, especially unusually large spikes in heroin or unspecified drug overdose fatalities Screen specimens using an ELISA test that can detect fentanyl  If positive, GC/MS to detect possible analogs Standardized methods for determining cause and reporting the death  SAMHSA consensus definitions
  22. 22. Expand Use of Naloxone Health Care Providers • Multiple dosages of naloxone may be needed due to fentanyl potency • Ensure sufficient supply of naloxone available to first responders Harm Reduction • Expand access to people at risk for opioid overdose and their family members • Provide take-home naloxone kits to people who use heroin and/or misuse opioid analgesics—or know people that do • Train on effectively administering naloxone • Emphasize importance of overdose prevention tactics, rescue breathing, and calling 911
  23. 23. Longer Term: HHS Effort to Reduce Opioid Overdose, Death and Dependence • Providing training and educational resources, including updated prescriber guidelines, to assist health professionals in making informed prescribing decisions • Expanding the use of Medication-Assisted Treatment (MAT): Combines the use of medication with counseling and behavioral therapies to treat substance use disorders • See http://www.hhs.gov/about/news/2015/03/26/hhs- takes-strong-steps-to-address-opioid-drug-related-overdose- death-and-dependence.html#
  24. 24. Acknowledgements • NFLIS, Drug Enforcement Administration, Office of Diversion Control • Ohio Department of Health
  25. 25. Overview of the Ohio EpiAid on Fentanyl-Related Overdose Mortality Epi-Aid Team Erica Spies, PhD, MS CDC/NCIPC/DVP Amanda Garcia-Williams, PhD, MPH CDC/NCIPC/DVP Alexis Peterson, PhD CDC/NCIPC/DUIP John Halpin, MD, MPH CDC/NCIPC/DUIP Matt Gladden, PhD CDC/NCIPC/DUIP Jon Zibbell, PhD CDC/NCIPC/DUIP National RX Drug Abuse & Heroin Summit March 29, 2016 The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention.
  26. 26. Fentanyl Health Alert in Ohio September, 2015
  27. 27. Fentanyl Deaths in Ohio
  28. 28. EpiAid Objectives • Characterize the population experiencing fentanyl-related overdose deaths and compare it with the population experiencing heroin- related and prescription opioid overdose deaths. • Identify key risk factors for fentanyl-related overdose deaths that can be targeted by prevention activities. • Provide epidemiologic and qualitative information to improve the public health response and assist in the development of recommendations. • Identify strategies to aid the Ohio Department of Health in monitoring and preventing future fentanyl-related overdose deaths.
  29. 29. EpiAid Data Sources • Quantitative data – Vital Statistics – Coroner/Medical Examiner Reports and Toxicology • Abstracted into the unintentional drug overdose module in the National Violent Death and Reporting System (NVDRS) – OARRS data (Ohio’s PDMP) – Emergency Dept. chief complaint and triage notes – Emergency Medical Services • Qualitative data – Coroners/Medical Examiners – Harm Reduction groups • Overdose prevention • Syringe Service Programs – State and local public health – State and local law enforcement – Treatment Providers – Office of Substance Abuse Monitoring (OSAM)
  30. 30. Supplemental Data • National Forensic Laboratory Information System – NFLIS – Run by Drug Enforcement Administration – Contains data on >90% of all drug confiscations tested in forensic labs around the country • Prescription Behavior Surveillance System – PBSS – Surveillance system which tracks prescriber behavior data for controlled substances in 12 states (including Ohio) – Prescription fentanyl rates queried for 2014
  31. 31. Results from Quantitative Data
  32. 32. Fentanyl-Related Unintentional Overdose Deaths Epicurve 21 54 63 17 15 38 35 44 44 53 62 80 81 80 98 124 89 0 20 40 60 80 100 120 140 January-14 February-14 March-14 April-14 May-14 June-14 July-14 August-14 September-14 October-14 November-14 December-14 January-15 February-15 March-15 April-15 May-15 CaseCounts 20152014
  33. 33. 2013 2014 2015 Comparison of Fentanyl-related Overdoses to Reported Fentanyl Drug Seizures, 2013 – May 2015
  34. 34. Heroin and Fentanyl-related Deaths by Quarter: Jan. 2013 – March 2015
  35. 35. Geographic Distribution  60 of Ohio’s 88 counties experienced at least one fentanyl-related overdose death in 2014.  Highest number occurred in large (246) and moderately-sized (200) metropolitan areas. – 2/3 of all fentanyl-related deaths from 8 counties  Highest rate of fentanyl-related deaths, however, occurred in moderately-sized metropolitan areas (6.6 per 100,000 people) and rural counties adjacent to metro areas (4.7/100,000 people).
  36. 36. Coroner/Medical Examiner Data Characteristic of Fentanyl decedents Percent Died in a house or apartment 81.8% At least 1 bystander present 72.3% EMS present 82.2% Naloxone administered 40.8% Route of Fentanyl Administration Unknown 57.7% Injection 39.5% Drug paraphernalia at scene 48.5% Drugs found at scene 14.3% Track marks on body 26.1%
  37. 37. Coroner/Medical Examiner Data Medical History from C/ME record Fentanyl Heroin Mental health problem indicated 22.8% 24.1% Substance abuse problem indicated 82.6% 74.7% Recent release from jail, rehabilitation or hospital 10.4% 10.8% Previous drug overdose reported 13.9% 12.0%
  38. 38. OARRS Data • Majority of heroin and fentanyl decedents not prescribed opioids at the time of death (~75%) • However, over 60% of fentanyl and heroin decedents had a history of opioid prescription at some point in the 6-7 years preceding their death. Of those: – 50% were prescribed a max opioid dose of >= 50 MME – 35% were prescribed a max opioid dose of >= 90 MME
  39. 39. 0 500 1000 1500 2000 2500 3000 Q1 2014 Q2 2014 Q3 2014 Q4 2014 Q1 2015 Q2 2015 NumbnerofOhioResidents Naloxone Administrations Compared to Opioid Mortality: Q1 2014 to Q2 2015 Patients receiving 1 dosage of naloxone Patients receiving 2 or more dosages of naloxone Any Opioid death
  40. 40. Key Stakeholder Meetings • Fentanyl being produced in several countries – Mexico, China, India • Entry into U.S. is predominantly through Mexico – Ohio is a drug distribution point for the upper Midwest and east coast – Rising trend towards internet purchases delivered via USPS/FedEx • Fentanyl-cut heroin mostly marketed as heroin, with user typically unaware of its presence in the product – Designed to improve the euphoric effect and attract heroin users • Heroin is easily accessible, highly potent and far cheaper than Rx opioids
  41. 41. Key Themes across Stakeholder Groups • Naloxone supply and utilization concerns – Rising demand and rising costs – Need to involve EMS when administered by laypersons • Lack of affordable/accessible drug treatment services – Supply of services does not meet the demand – Need to leverage/train more primary care physicians to play role in addiction services • Stigma – People who use drugs (PWUD) are a highly stigmatized group, which can hamper efforts to provide services • Affects support for syringe exchange programs and other evidenced- based harm reduction services • Affects support for evidence-based medicated assisted treatment (MAT) in favor of abstinence-only treatment modalities
  42. 42. Recommendations
  43. 43. Public Health Surveillance • Support continued testing for fentanyl by coroners and medical examiners • Continue to collect and analyze Coroner/Medical Examiner data – Utilize unintentional drug overdose module in NVDRS • Refine syndromic surveillance of ED data • Utilize drug seizure data available from DEA • Track naloxone administration data
  44. 44. Targeted Public Health Response • 8 high burden counties (2/3 of fatalities) • History of mental illness puts one at higher risk • Persons recently released from an institution (jail, hospital, rehabilitation) are at higher risk • Support treatment during incarceration • Assist with transitioning to treatment upon release • Consider Naloxone distribution to future dischargees who are at risk
  45. 45. Facilitate Overdose Response • EMS – Ensure availability of Naloxone, particularly in high burden counties – Raise awareness of fentanyl potency, importance of early administration of naloxone, and potential need for multiple naloxone dosing • Layperson – Educate on importance of activating EMS early, even after lay administration of naloxone
  46. 46. Fentanyl-Induced Chest Wall Rigidity • May be another factor leading to rapid death in illicit fentanyl overdose • Effect is not dose- dependent • 50% of fentanyl decedents in Franklin county had varying levels of fentanyl, but no detectable norfentanyl metabolite – Death within 2 minutes
  47. 47. Larger Issues • Improved Opioid Rx practices • Rising cost of Naloxone • Improved access to Addiction Services, particularly MAT • Education initiatives to reduce stigma associated with substance abuse – Addiction as an illness, not a character flaw – Education regarding effectiveness of MAT
  48. 48. Ohio Department of Health Richard Hodges Mary DiOrio Jolene Defiore-Hyrmer Judi Mosely Alexandria Jones Luke Werhan Kara Manchester Katelyn Yoder Kelli Redd Richard Thompson Brian Fowler Ohio Department of Mental Health and Addiction Services Andrea Boxill Tom Sherba Sarah Smith Molly Jones Mark Hurst Ohio Association of County Behavioral Health Authorities Dontavius Jarells Ohio Department of Public Safety John Born Tim Erskine Ryan Frick Ohio Attorney General’s Office Erin Reed Ohio Coroners Association David Corey Ohio State Medical Association Brent Mulgrew Ohio Board of Pharmacy Steve Schierholt Cameron McNamee Chad Garner Medical Board of Ohio AJ Groeber Ohio Board of Nursing Betsy Houchen Ohio Department of Aging Bonnie Burman Cuyahoga County/ Cleveland Tom Gilson Joan Papp Emily Metz Terry Allan Vince Caraffi Jerry Jason Jennifer Tulli Hamilton County/ Cincinnati Judith Feinberg Tim Ingram Lakshmi Sammarco Tim Ingram Erin Winstanley Noble Maseru Shawn Ryan Mike Lyons Mark Schoonover John Taylor Tom Synan Steve Walkenhorst Josh Arnold Montgomery County/ Dayton Kent Harshbarger Ken Betz Matt Juhascik Rob Carlson Jeff Cooper Barbara Marsh Joyce Close Colleen Smith Richard Biehl James Mullins Gary Lowe Brian Johns Phil Plummer Rob Streck Mike Brem Bruce Langos Virgil McDaniel John Goris Sue McGatha Carol Smerz Monica Sutter Scioto County/Portsmouth Darren Adams Chris Smith Lisa Roberts David Byers Marissa Wicker Robert Ware David Hall Rose Uradu JoAnna Krohn US Department of Justice Steve Dettelbach Drug Enforcement Administration Christopher Melink Centers for Disease Control and Prevention (CDC) Grant Baldwin Rita Noonan Arlene Greenspan Tamara Haegerich Erin Sauber-Schatz Karin Mack Kevin Vagi J. Logan Cory Ferdon Elizabeth Conrey CDC EIS Program Carolyn McCarty Danice Eaton Kris Bisgard Acknowledgements
  49. 49. Extra Slides
  50. 50. Quantitative Data Methodology • Vital Statistics – Analyzed state-wide data for January 2014 through May 2015 • Coroner/Medical Examiner records – Focused on 14 highest burden counties – Compared fentanyl, heroin, and Rx opioid cases – Data abstracted into state’s NVDRS surveillance system • Additional “Drug Overdose” module which captures scene characteristics, medical history, and drug abuse history • PDMP/OARRS data – Controlled substance prescribing histories for 2007-2014 • Including max opioid dose received (>50 MME, >90 MME) – Data linked to Vital Statistics death certificate data
  51. 51. Qualitative Data Methodology • Series of key stakeholder meetings focused on: – perspectives on etiologic factors – perspectives on individual risk factors – activities and role in response to the epidemic – key issues that need to be addressed to facilitate response • Notes analyzed for themes across stakeholder groups
  52. 52. Letter of Invitation from state of Ohio • “The primary goal for the investigation is to characterize the population experiencing fatal fentanyl overdoses and identify key risk factors that can be targeted for prevention efforts” • “Secondary goals may be identified that could include recommendations for enhancements of surveillance and identification of drug overdose outbreaks.”
  53. 53. 5.43 5.54 5.58 5.39 5.12 5.16 5.09 4.96 1.44 1.39 1.34 1.32 1.22 1.19 1.17 1.14 0.00 1.00 2.00 3.00 4.00 5.00 6.00 Jan- Mar 2013 Apr- Jun 2013 Jul- Sep 2013 Oct- Dec 2013 Jan- Mar 2014 Apr- Jun 2014 Jul- Sep 2014 Oct- Dec 2014 NUMBEROFPRESCRIPTIONSPER1,000POPULATION Ohio: Prescription Rates for Fentanyl and Other Synthetic Opioids, Per Quarter, 2013 - 2014 Fentanyl LA and SA Meperidine, pentazocine, and tapentadol
  54. 54. Characteristics of Fentanyl-Related Decedents, January 2014 to May 2015 Characteristic N (%) Mean Age (Years) 38 (Range: 17-92) Sex Female Male 306 (31) 692 (69) Race White Black Other 890 (89) 94 (9) 14 (2) Marital Status Never Married Married Divorced/separated Widowed Not Classifiable 545 (55) 180 (18) 235 (23) 27 (3) 11 (1) Education Less than High School High School Graduate/GED Some College College Graduate Post College Degree Unknown 224 (22) 518 (52) 199 (20) 30 (3) 7 (1) 20 (2)
  55. 55. OSAM: Ohio Substance Abuse Monitoring • - Collects data on drug abuse from around the entire state. • - Qualitative data collected from focus groups and individual qualitative interviews with active and recovering drug users and community professionals (treatment providers, law enforcement officials, etc.).
  56. 56. OSAM findings • “Users, treatment providers and law enforcement from across Ohio reported that much of the heroin supply is adulterated with fentanyl and that fentanyl is often sold as heroin.” • “Several law enforcement agencies throughout Ohio reported purchasing heroin undercover only to discover through lab testing that the heroin specimen was actually fentanyl.” • “When buying white powdered heroin, Youngstown users believed five out of 10 times that what they purchased was fentanyl rather than heroin.
  57. 57. Public Health Messaging http://knowyoursource.ca/what-is-fentanyl/
  58. 58. Traci C. Green, PhD, MSc Deputy Director, Boston Medical Center Injury Prevention Center Boston Medical School, Department of Emergency Medicine, Boston, MA Associate Professor of Emergency Medicine & Epidemiology The Warren Alpert School of Medicine at Brown University, Rhode Island Hospital Emerging Illicit Fentanyl Overdose Epidemic: the View from Rhode Island Brandon Marshall, PhD Assistant Professor of Epidemiology Brown School of Public Health, Providence, RI
  59. 59. Disclosures-Traci C. Green • No conflicts to disclose • Funding: Centers for Disease Control & Prevention (CDC RFA- CE15-1501); Agency for Healthcare Research and Quality (R18 HS024021-01 Green)
  60. 60. Learning Objective • Describe one state’s experiences with and responses to the fentanyl overdose epidemic
  61. 61. Introduction of Reformulated OxyContin: Changes in Route of Administration Source: Butler, S.F., Cassidy, T.A., Chilcoat, H., Black, R.A., Landau, C., Budman, S.H., Coplan, P. (In press). Abuse rates and routes of administration of reformulated extended release oxycodone: Initial findings from a sentinel surveillance sample of individuals assessed for substance abuse treatment. Journal of Pain. 35.7% 52.7% 6.4% 54.5% 15.9% 25.4% 4.2% 76.1% 0% 10% 20% 30% 40% 50% 60% 70% 80% Inject Snort Smoke Oral PercentofAbusers Original OxyContin® Before (n= 2,894 ) Reformulated OxyContin® After (n=1,705 )
  62. 62. Trends in Prevalence of Past 30-Day Use of Heroin 0.0% 1.0% 2.0% 3.0% 4.0% 5.0% 6.0% 7.0% 8.0% 9.0% 10.0% Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 2008 2009 2010 2011 2012 Useper100ASI-MVAssessments Heroin Prevalence Heroin Initiates Heroin Initiate = Indicated past 30-day use of heroin and first use of heroin within the past year Reformulation of OxyContin Reformulation of Opana ER Source: ASI-MV dataset, PMP-U Study 2013, PI: Green
  63. 63. Counterfeits Counterfeit OxyContin (fentanyl) seized in Edmonton, Canada 9/24/14, linked to 2 deaths
  64. 64. Unintentional drug poisoning deaths Rhode Island 2009-2014 0 10 20 30 40 50 60 70 80 2009Q1 2009Q2 2009Q3 2009Q4 2010Q1 2010Q2 2010Q3 2010Q4 2011Q1 2011Q2 2011Q3 2011Q4 2012Q1 2012Q2 2012Q3 2012Q4 2013Q1 2013Q2 2013Q3 2013Q4 2014Q1* total illicit drug illicit & med medication Total Source: RI Office of State Medical Examiner Acetyl Fentanyl Outbreak 2014 Illicit, Synthetic Fentanyl Outbreak
  65. 65. 0 5 10 15 20 25 30 35 40 Total accidental drug deaths opioid of any type fentanyl of probable illicit source *provisional data 2014 Illicit, Synthetic Fentanyl Outbreak 2015 Illicit, Synthetic Fentanyl Outbreak
  66. 66. •All but 4 cities with overdose deaths reporting fentanyl •Death rates higher in places outside of Providence, urban centers
  67. 67. Jan 1 to Oct 16, 2015 Characteristic N or Mean % or StDev Age (mean, standard deviation) 42.2 13.6* Gender (n,%) Male Female 120 42 74.1%* 25.9% White (n,%) 152 93.8% Location of incident (n,%) Own residence 120 74.1% Someone else’s residence 16 9.9% Other 13 8.0% Missing 13 8.0% Evidence of injection drug use (n,%) 44 42.0%* Substance Presences (n,%) Fentanyl 79 48.8% Alcohol 44 27.1% Benzodiazepine 33 20.4% Suspected Heroin (Morphine intoxication) 55 34.0% Cocaine as a contributing cause of death 59 36.4% Buprenorphine § § Methadone 15 9.3% Oxycodone 19 11.7% Hydrocodone § § Source: RI Office of State Medical Examiners
  68. 68. 76% Fentanyl only
  69. 69. Why Fentanyl? FENTANYL 0.0 0.0625 0.125 0.187 0.25 Mean SEM Mean SEM Mean SEM Mean SEM Mean SEM Bad Effect 0 0.0 10.4 10.4 5.3 4.2 6.1 6.1 8.3 7.2 Good Effect 0.1 0.1 1.1 0.8 4.6 2.3 27.3 a 9.8 46.3 a 10.5 High 0.0 0.0 6.9 6.9 9.4 6.4 21.1 a 8.1 29.3a,b,c ,d 13.0 Irritable 22.9 13.7 20.1 12.5 25.6 14.1 27.0 14.1 19.4 11.2 Like 12.5 12.5 13.0 12.4 3.9 2.2 36.5 a 12.7 52.8 a 12.5 Mellow 21.3 8.8 28.4 9.9 34.1 11.2 39.9 a 12.2 50.9 a 13.4 Nauseated 12.6 12.5 9.9 9.9 18.6 12.2 8.4 8.4 9.6 8.3 Potent 0.0 0.0 0.6 0.4 2.4 1.5 27.5 a 9.2 31.0a,c,d 12.6 Quality 12.5 12.5 13.4 12.4 15.4 12.2 26.0 13.5 38.4 a 12.2 Sedated 2.8 2.6 8.5 8.5 12.0 9.5 20.8 a 10.0 35.4 a 9.0 Social 17.0 8.6 17.6 9.6 29.1 10.3 47.5 a 12.2 36.1 a 14.6 Stimulated 10.9 7.7 17.1 9.4 17.1 7.7 29.3 a 10.2 37.8 a 12.1 Talkative 13.5 7.0 18.1 9.7 23.8 11.4 40.3 a 13.0 39.1 a 14.8 Want Heroin 52.0 16.5 56.4 17.5 57.8 16.7 57.9 17.5 70.3 a 12.5 Would Pay 2.5 2.5 2.6 2.5 3.0 2.4 8.0 a 2.7 8.5a,b,d 2.0 Comer et al., 2008 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3787689/
  70. 70. Fentanyl Trends & What they Imply • Responsive, flexible, interdisciplinary • Bridge & Create better data  Emergent trends, public health surveillance protocols  Specimen collection, rapid testing, presumptive tests • Consistent, careful messaging: call/text 911 • Innovate interventions  Public Health/Public Safety partnerships, responses  Invest in highest risk settings • Massive Demand Reduction efforts, investments  Prioritize Evidence-Based Treatment, Recovery Supports • Mitigate Risk & Reduce Stigma at every opportunity
  71. 71. Strategic Plan for Overdose & Addiction • Locally derived, data driven, evidence based • Sustainable • Responsive • Extraordinary • Measureable • Stigma-reducing “Dashboard”: public facing, privileged stakeholder access for transparency, accountability Communication strategy to market approach
  72. 72. Treatment Strategy: Every Door is the Right One Medication assisted treatment (methadone, buprenorphine, naltrexone) at every location where opioid users are found • Medical system (EDs, hospitals, clinics), criminal justice system, opioid treatment programs, community. Centers of Excellence in MAT • DATA waiver required for new medical licensure, incentives for others • Remove Prior Authorizations, increase bundled payments for buprenorphine Buprenorphine and Methadone in Baltimore: Schwartz et al. AJPH 2013.
  73. 73. Prevention Initiative: Targeted Safer Prescribing and Dispensing • Reduce dangerous prescribing of benzodiazepines through PDMP alerts, provider education & “detailing” • Guidelines for use of benzodiazepines in MAT and pain Source: Park TW et al., BMJ 2015
  74. 74. Naloxone distribution in Rhode Island January 2014 to June 2015 by distribution source and route (IN=intranasal, IM=intramuscular). Source: RI DOH Rescue Strategy: Naloxone as the Standard of Care – Leverage PDMP for tracking Naloxone dispensing & develop a parallel system for tracking community use/dispensing (e.g., ED, police) – Naloxone “trust fund” for community & first responder purchases – De-stigmatize indication for naloxone by establishing naloxone prescription as standard of care with any C2, syringe sale, or opioid+benzo prescription filled within 30 days
  75. 75. Recovery Strategy: Expand Recovery Supports • Large-scale expansion of peer-based recovery coach reach and capacity – ED, prison, community, “outbreak” based street outreach Source: L. Samuels, 2015
  76. 76. The Dashboard EMS Naloxone Admin. Department of Corrections 48-Hour Reporting Database; Hospital Records CME Overdose Death Data PMP Opioid Prescribing Data Buprenorphine, Treatment Availability Pharmacy Naloxone Distribution
  77. 77. Real-Time Ethnographic Surveillance Open-ended interviews (n=50) Survey v.1 (n=37) 150 participants total, each 6-month surveillance cycle: • 1-50: survey and interview • 51-150: survey only • Drug use • Naloxone • Fentanyl • Treatment • Overdose • Diversion • Race/ethnicity • 911/rescue • non-Rx bup and methadone • Ease of finding diverted drugs • Suppliers • Capture detailed treatment history • Characteristics of dealer relationships and market strategies • Motivations in seeking diverted bup vs. heroin or Rx pain medications • String variables converted to multiple choice (barriers to care, time, etc.) • Verbal follow-up questions established Survey v.2 (n=13) Survey v.3 (n=100)
  78. 78. Injectors know fentanyl can be deadly. “I’d rather not have the fentanyl in it, because it’s dangerous. You know, you can go out. You could die. A lot of people die, I’m sure you’ve heard, of dope mixed with fentanyl. And people, they dunno that there’s fentanyl in the dope, and they’ll do too much, know what I’m saying, and they’ll go out. Know what I’m saying? And not come back.”
  79. 79. Most injectors prefer to avoid fentanyl. About half claim fentanyl can be identified prior to injection. “I knew right away because it was clear. When it’s really dark, it’s usually heroin. But when it’s lighter it’s always fentanyl. It’s even whiter in the bag. Way whiter in the needle. It’s almost like you’re shooting water. My hit, I want it dark.”
  80. 80. Risk reduction strategies exist, are imperfect. Using the same supplier: “Usually our guys have the same batch and use it for a long period of time…I’m not like out on the street buying it from random people. I know what I’m buying. So, that’s kinda how I—I don’t go through any new people. I don’t like chancing that.”
  81. 81. Risk reduction strategies exist, are imperfect. Most people just make the best of it: “I’m an everyday heroin user, and certain batches of dope that goes around has fentanyl in it, so if I look at the color of it, I know, I call my guy and he’ll tell me yea, there’s fentanyl in it, and I choose whether or not to use it.”
  82. 82. Some have reasons to trust their suppliers… “Last year, you remember that school teacher that nodded out…at the steering wheel? She shot in the parking lot, and her head hit the horn. [My dealer] was her dealer also…that’s how he found out his dope had fentanyl in it. So, we thought his dope was killer, course. So we kept buyin buyin buyin it and then he came by one day and said “I’m not selling that any more.” Cause of the school teacher…cause he didn’t want to get in trouble.”
  83. 83. Q1 2016 Ethnographic Surveillance Summary • Most users report preferring fentanyl-free heroin • Fentanyl is pervasive and it’s use is driven by supply, NOT demand – Fentanyl is cheap, available, efficient. The fact that users don’t like it doesn’t seem to matter – Users have little opportunity to inspect their product and have no recourse for protecting their basic rights as product consumers • Few users feel like they have any way to protect themselves from the risks of fentanyl except treatment, abstinence from street drugs
  84. 84. Fentanyl Trends & What they Imply • Responsive, flexible, interdisciplinary • Bridge & Create better data  Emergent trends, public health surveillance protocols  Specimen collection, rapid testing, presumptive tests • Consistent, careful messaging: call/text 911 • Innovate interventions  Public Health/Public Safety partnerships, responses  Invest in highest risk settings  Safe consumption spaces?  Targeted media campaign for active users • Massive Demand Reduction efforts, investments  Prioritize Evidence-Based Treatment, Recovery Supports • Mitigate Risk & Reduce Stigma at every opportunity • Market “safety”: supply-side interventions?  Supplier-side interventions? Incentivize Supplier Harm Reduction? Regulation?
  85. 85. Acknowledgements • Max King, MS • Todd Hampson, BA • Jody Rich, MD MPH • Jennifer Carroll, PhD • Lauren Rubinstein, PhD • Alexandra Macmadu, MS • Jonathan Goyer
  86. 86. • Extra slides
  87. 87. Comer et al., 2008 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3787689/
  88. 88. Targeted Media Campaign Examples
  89. 89. The Emerging Illicit Fentanyl Overdose Epidemic: Perspectives from the National and State Levels Presenters: • R. Matthew Gladden, PhD, Behavioral Scientist, PDO Surveillance and Epi Team, Division of Unintentional Injury Prevention, CDC • John Halpin, MD, MPH, Medical Officer, PDO Surveillance and Epi Team, Division of Unintentional Injury Prevention, CDC • Traci Green, PhD, MSC, Deputy Director, Boston Medical Center Injury Prevention Center, and Associate Professor of Emergency Medicine, Boston University Federal Track Moderator: Regina M. LaBelle, JD, Chief of Staff, White House Office of National Drug Control Policy, and Member, Rx Summit National Advisory Board

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