Karl Williams, MD, MPH Medical Examiner Allegheny County
Feb 25, 2016
Karl Williams, MD, MPH
Medical ExaminerAllegheny County
The Overdose Problem in Allegheny County2008 - 2011
Allegheny CountyOverdose Prevention
Coalition
July 31, 2012
Karl E. Williams, MD, MPHChief Medical Examiner
Allegheny County
National Statistics
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%).
Florida Overdose Data – 2003 - 2009
ACOME Drug Deaths as % of Morgue Cases
2011 2010 2009 2008 2007 20060.00%
5.00%
10.00%
15.00%
20.00%
25.00%
22.10%
19.62%18.99%
20.80%
18.70%
17.08%
Drug Deaths as % of Morgue Cases
Drug Death as % All Morgue Cases
ACOME Drug Deaths as % of Accidental Deaths
2011 2010 2009 2008 2007 20060.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
60.42%58.06% 57.77% 56.63%
49.89% 48.23%
Drug Deaths as % of Accidental Deaths
Drug Death as % Accidental Deaths
ACOME Drug Deaths by Age Group
0 thru 19 20 thru 24 25 thru 29 30 thru 34 35 thru 39 40 thru 44 45 thru 49 50 thru 54 55 thru 59 60 thru 69 70 or >0.00%2.00%4.00%6.00%8.00%
10.00%12.00%14.00%16.00%18.00%
3.14%
5.83%
11.66%
8.07%10.31%
13.45%15.25%
17.04%
10.31%
4.04%
0.90%
2009 % of Drug Deaths per Age Group
0 thru 19 20 thru 24 25 thru 29 30 thru 34 35 thru 39 40 thru 44 45 thru 49 50 thru 54 55 thru 59 60 thru 69 70 or >0.00%2.00%4.00%6.00%8.00%
10.00%12.00%14.00%16.00%18.00%20.00%
2.97%
9.75% 9.32%
5.08%
8.90%
16.10%18.64%
15.68%
9.32%
2.54% 1.69%
2008 % of Drug Deaths per Age Group
ACOME Drug Deaths by Age Group
0 thru 19 20 thru 24 25 thru 29 30 thru 34 35 thru 39 40 thru 44 45 thru 49 50 thru 54 55 thru 59 60 thru 69 70 or >0.00%2.00%4.00%6.00%8.00%
10.00%12.00%14.00%16.00%18.00%
2.30%
6.13%
11.49%12.64% 12.26%
13.41%
16.86%
13.41%
7.28%
4.21%
2011 % of Drug Deaths per Age Group
0 thru 19 20 thru 24 25 thru 29 30 thru 34 35 thru 39 40 thru 44 45 thru 49 50 thru 54 55 thru 59 60 thru 69 70 or >0.00%2.00%4.00%6.00%8.00%
10.00%12.00%14.00%16.00%18.00%20.00%
1.76%
6.61%
11.01% 10.57%8.81%
12.78%14.10%
17.18%
11.01%
4.41%1.76%
2010 % of Drug Deaths per Age Group
ACOME Drug Deaths by Race/Sex
White Black Other0
20406080
100120140160 151
201
76
13
2011 Drug Deaths by Race / SexMale Female
White Black Other0
20406080
100120140 124
28
1
63
11
2010 Drug Deaths by Race / SexMale Female
ACOME Drug Deaths by Race/Sex
White Black Other0
20406080
100120140 131
28
2
57
5
2009 Drug Deaths by Race / SexMale Female
White Black Other0
20406080
100120140160 144
19
56
16
2008 Drug Deaths by Race / SexMale Female
Figure 2. Number of drugs listed on death certificates, unintentional poisonings, Allegheny County, 2008-2010
127%
2 or 352%
4+21%
ACOME Drug Deaths TotalSingle or Combined
Case Year
Total Drug Deaths
1 Drug
2 Drug
3 Drug
4 Drug
5 Drug
6 Drug
7 Drug
2011 261 89 72 56 27 12 2 32010 227 61 69 52 28 9 1 72009 223 52 57 61 24 20 3 62008 235 81 56 58 22 13 2 3
ACOME Accidental Overdose Cases
Cocaine; 93
Alcohol; 66
Heroin; 62
Morphine; 49
Methadone; 37
Alprazolam; 28
Oxycodone; 19Citalopram; 18
2008 Top 8 Drugs FoundSingle or Combined OD
CocaineAlcoholHeroinMorphineMethadoneAlprazolamOxycodoneCitalopram
ACOME Accidental Overdose Cases
Cocaine; 76
Heroin; 63
Alcohol; 61Morphine; 40
Alprazolam; 39
Methadone; 38
Oxycodone; 33
Hydrocodone; 25
2009 Top 8 Drugs FoundSingle or Combined OD
CocaineHeroinAlcoholMorphineAlprazolamMethadoneOxycodoneHydrocodone
ACOME Accidental Overdose Cases
Cocaine; 86
Alcohol; 56
Heroin; 50Morphine; 48
Oxycodone; 40
Alprazolam; 39
Methadone; 32
Diazepam; 20
2010 Top 8 Drugs FoundSingle or Combined OD
CocaineAlcoholHeroinMorphineOxycodoneAlprazolamMethadoneDiazepam
ACOME Accidental Overdose Cases
Heroin; 95
Cocaine; 83
Alcohol; 60
Oxycodone; 51
Alprazolam; 41
Methadone; 26
Diazepam; 24
Morphine; 24
2011 Top 8 Drugs FoundSingle or Combined OD
HeroinCocaineAlcoholOxycodoneAlprazolamMethadoneDiazepamMorphine
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 drug eg. Cocaine– Multidrug toxicity
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
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
Metabolism of Heroin
6-MAMA
t ½ = 9 mins.
t½ = 39 mins.
t½ = 4 to 6 hours
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
Heroin: bricks, bundles, stamp bags…
Paraphenalia
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
Figure 3. Most common substances detected by toxicology, unintentional drug overdose deaths, Allegheny County, 2008-2010
Morphine
Cocaine*
Ethanol
6-MAM
Codeine
Alprazolam
Methadone
Oxycodone
Hydrocodone
Fentanyl
Citalopram
Diazepam05
101520253035404550 47
3834
2419 19 17 16
139 8 7
% o
f dea
ths
*Cocaine metabolites include benzoylecgonine, ecgonine methyl ester, cocaethylene
Figure 1. Most common drugs listed on death certificates, unintentional drug overdose deaths, Allegheny County, 2008-2010
CocaineHeroin
Alcohol
Morphine
Methadone
Alprazolam
Oxycodone
Hydrocodone
Fentanyl
Diazepam
CitalopramCodeine
05
10152025303540 38
27 26
2016 16
138 8 6 6 5
38
61
Listed on death certificate After reclassification
% o
f dea
ths
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
Acknowledgements
• Kristen Mertz, MD, MPH – Department of epidemiology/GSPH/University of Pittsburgh
• Patricia Rekiel – Computer Analyst, ACOME• Jennifer Jennsen – Chief Toxicologist, ACOME