Recommendations for Fatal Drug Overdose Surveillance Methodology and Data Quality Improvements: A Follow-up to the Safes States Injury Surveillance Workgroup on Poisoning CSTE Overdose Subcommittee Presentation 2016 Annual Meeting Safe States Alliance April 12-14, Albuquerque, NM
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Recommendations for Fatal Drug Overdose Surveillance ......[hallucinogens], not elsewhere classified, undetermined intent) X85 (Assault by drugs, medicaments and biological substances)
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Recommendations for Fatal Drug Overdose Surveillance
Methodology and Data Quality Improvements:
A Follow-up to the Safes States Injury Surveillance
Workgroup on Poisoning
CSTE Overdose
Subcommittee Presentation
2016 Annual Meeting
Safe States Alliance
April 12-14, Albuquerque, NM
Presenters and Co-Authors
• Dr. Svetla Slavova, PhD, Kentucky Injury Prevention and Research Center
• James W Davis, MA, New Mexico Department of Health
• Dr. Denise Paone, EdD, New York City Department of Health and Mental Hygiene
• Barbara Gabella, MSPH, Colorado Department of Public Health and Environment
Co-Authors:
• Dr. Jennifer C Sabel, PhD, Washington State Department of Health
• Dr. Dagan A Wright, PhD, MSPH, Oregon Health Authority – Department of
Public Health
Fatal Drug Overdose Surveillance
“Levels 1 - 4”
Level 4: Toxicology and
Literals
Level 3: Literal text from death certificate
Level 2: Multiple Cause
Level 1: Basic Underlying
cause of death file
Agenda
• Safe States & CSTE (Denise)
• Levels 1 and 2 (Svetla)
• Level 3 & Epi tool for everyone (Jim)
• Level 4 (Denise)
• Lessons learned paper (Svetla, Denise, Jim)
• Future & your ideas (Barbara)
Safe States Background
• Safe States Poisoning
Workgroup – 2008
• Safe States forms Injury
Surveillance Workgroup (ISW7)
• ISW7 Publication – 2012
• Conferences of CDC, Safe
States, CSTE - 2012
CSTE Background
• Council of State and Territorial Epidemiologists (CSTE)
• CSTE Drug Overdose
– Willing and wanting to test ISW7 indicators
– Providing organizational base for effort
• Real partnership with Safe States – liaison
• Scott Proescholdbell
www.cste.orgUsing the power of epidemiology to improve
produced the Safe States ISW7 recommended indicators
Drug Type Unintentional Suicide Undetermined Homicide
Nonopioid analgesics,
antipyretics and anti-
rheumatics
X40 X60 Y10
X85
Sedative-hypnotic,
psychotropic
X41 X61 Y11
Narcotics and
psychodysleptics
(hallucinogens), NOS
X42 X62 Y12
Other drugs acting on
CNS
X43 X63 Y13
Other and unspecified
drugs
X44 X64 Y14
Level 1 Method
Level 1 Results(Underlying Cause of Death only)
Comparing states/jurisdictions on drug overdose rates by
intent could be misleading!
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
Percentage of Drug Overdose Deaths with "Undetermined" Intent, By State, 2014
Level 1 Results
Level 1 Results
CSTE Overdose Subcommittee
Recommendations
• It is better to report all drug overdoses, regardless of
intent, for state-to-state comparisons.
• Categorization by intent is still useful, for example, to
examine the proportion of the drug overdose deaths
by intent over time within a given state/jurisdiction.
Fatal Drug Overdose Surveillance
“Levels 1 - 4”
Level 4: Toxicology and
Literals
Level 3: Literal text from death certificate
Level 2: Multiple Cause
Level 1: Basic Underlying
cause of death file
Level 2 Method
• Use underlying cause of death and multiple causes of death to identify drugs contributing to overdose deaths.
• When no specific drugs/classes of drugs are listed on the death certificate, the overdose is attributed to– “Other and Unspecified Drugs”, coded with ICD-10 code T50.9.
• An overdose death could be attributed to “Other and Unspecified Drugs” when – it involves drug that cannot be classified under any other existing
category (e.g., “bath salts”).
7,577
8,297
0 2000 4000 6000 8000 10000
Y14 (Poisoning by and exposure to other and unspecified drugs,medicaments and biological substances, undetermined intent)
Y12 (Poisoning by and exposure to narcotics and psychodysleptics[hallucinogens], not elsewhere classified, undetermined intent)
X85 (Assault by drugs, medicaments and biological substances)
X64 (Intentional self-poisoning by and exposure to other andunspecified drugs, medicaments and biological substances)
X62 (Intentional self-poisoning by and exposure to narcotics andpsychodysleptics [hallucinogens], not elsewhere classified)
X44 (Accidental poisoning by and exposure to other and unspecifieddrugs, medicaments and biological substances)
X42 (Accidental poisoning by and exposure to narcotics andpsychodysleptics [hallucinogens], not elsewhere classified)
U.S. Drug Overdose Deaths by Selected Underlying and Multiple Causes of Death, 2014
Cocaine (T40.5) Heroin (T40.1) Pharmaceutical opioids (T40.2, T40.3, or T40.4)
Level 2 Example Text & Codesfor underlying cause of death and multiple causes of death
Part I Part II Underlying Cause Multiple Causes of Death
How injury occurred Manner Line a Line b Line c Line d
Significantconditions
contributing to death
ICD-10 Code Text
1st in ICD-10 1 in Text
2nd in ICD-10 2nd in Text
3rd in ICD-10 3rd in Text
PRESCRIPTION DRUG OVERDOSE ACCIDENT ANOXIC BRAIN INJURY
SECONDARY TO INGESTION OF METHADONE X42
Accidental poisoning by and exposure to narcotics and psychodysleptics [hallucinogens], NEC G93.1
Anoxic brain damage, not elsewhere classified T40.3
Poisoning, methadone T50.9
Poisoning, Other and unspecified drugs
INJECTED HEROIN ACCIDENT HEROIN INTOXICATION X42
Accidental poisoning by narcotics and psychodysleptics [hallucinogens], NEC F11.9
Unspecified mental and behavioral disorder T40.1
Poisoning, heroin
MULTIPLE DRUG INTOXICATION ACCIDENT
MULTIPLE DRUG INTOXICATION (OXYCODONE AND DIAZEPAM) X44
Accidental poisoning by and exposure to other and unspecified drugs T40.2
Poisoning, other opioids T42.4
Poisoning, Benzodiazepines T50.9
Poisoning, Other and unspecified drugs
USED TOXIC LEVEL OF BATH SALTS ACCIDENT
ACUTE ALPHA-PVP TOXICITY (BATH SALTS)
HISTORY OF DRUG ABUSE X44
Accidental poisoning by and exposure to other and unspecified drugs T50.9
Poisoning, Other and unspecified drugs F19.1 Harmful use
COMBINED DRUG TOXICITY ACCIDENT
COMBINED DRUG TOXICITY X44
Accidental poisoning by and exposure to other and unspecified drugs T50.9
Poisoning, Other and unspecified drugs
SUBJECT WAS FOUND UNRESPONSIVE IN BED BY A FAMILY SUICIDE DRUG OVERDOSE X61
Intentional self-poisoning (suicide) by and exposure to antiepileptic, sedative-hypnotic, antiparkinsonism, and psychotropic drugs,NEC T50.9
Poisoning, Other and unspecified drugs
Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple Cause of Death 1999-2014 on CDC WONDER Online Database, released 2015.
Data are from the Multiple Cause of Death Files, 1999-2014, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative
Program. Accessed at http://wonder.cdc.gov/mcd-icd10.html on Mar 30, 2016 1:51:15 PM
Level 2 Results
Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple Cause of Death 1999-2014 on CDC WONDER Online Database, released 2015.
Data are from the Multiple Cause of Death Files, 1999-2014, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative
Program. Accessed at http://wonder.cdc.gov/mcd-icd10.html on Mar 30, 2016 1:51:15 PM
Level 2 Results
Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple Cause of Death 1999-2014 on CDC WONDER Online Database,
released 2015. Data are from the Multiple Cause of Death Files, 1999-2014, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital
Statistics Cooperative Program. Accessed at http://wonder.cdc.gov/mcd-icd10.html on Mar 30, 2016 1:51:15 PM
Drug Overdose Deaths: Let’s Get Specific.
Slavova, S., Bradley O’Brien, D., Creppage, K., Dao, D., Fondario, A., Haile, E., Hume, B., Largo, T., Nguen, C.,
Sabel, J., Wright, D.
Public Health Reports.
July-August 2015. Volume 130, pg.339-342
CSTE Overdose Subcommittee
Recommendations
• The use of nonspecific language to identify specific drugs
on death certificates can result in undercounting various
drug classes.
• Ranking jurisdictions by specific drug types identified on
death certificates might be misleading and should be
accompanied by analysis of the level of completeness and
specificity of the jurisdictional data.
CSTE Overdose Subcommittee
Recommendations
Epidemiologists and other public health practitioners:
• Need to be aware of the quality and limitations of the death
certificate data in their jurisdiction,
• Evaluate when possible the level of completeness and
accuracy of their Multiple Cause of Death data, and
• Interpret the reported counts and rates with caution when
the proportion of deaths with ‘Other and Unspecified Drugs”
is considerable.
CSTE Overdose Subcommittee
Recommendations
At the state and local jurisdictions, where possible:
• Identify and address factors that contribute to differences in
how states record drug overdose deaths.
• Compare with medical examiner/coroner and state
toxicology laboratory records, exactly which drugs were
involved in deaths coded nonspecifically to provide better
estimates of the contributions of individual drug types to
their overdose problem.
Fatal Drug Overdose Surveillance
“Levels 1 - 4”
Level 4: Toxicology and
Literals
Level 3: Literal text from death certificate
Level 2: Multiple Cause
Level 1: Basic Underlying
cause of death file
Literal Text Fields
and
Beyond ICD-10
(Level 3)
Jim Davis
Drug Epidemiologist
New Mexico Department of Health
Level 3 Background
• In overdose deaths, text literals often contain:• Toxic effects of heroin [or oxycodone, or methamphetamine, …]
• Multiple drug (heroin, methadone and alcohol) intoxication
• Atherosclerotic cardiovascular disease and methamphetamine toxicity
• ICD-10 coding collapses some categories of interest
• Particularly the prescription opioids and benzodiazepines
• Text recognition not a new thing, but no general tool existed
for drug recognition in death data
Level 3 Methods & Epi Tool
• SAS program adapted from NM work
– Uses macro variables to define the variable names
– Can scan one or more of:• 4 variables for cause of death text
• 1 variable for “other factors” (part II)
• 1 variable for injury description
• Simple word-by-word search of specified literal text variables
• Common drugs found on death certificates listed by NCHS
• Specificity issues/completeness of the input data– “Mixed drug intoxication” is not specific
– Specificity varies by jurisdiction and over time
• Consistency over time – Different jurisdictions code differently
– Approaches to coding change over time
• Limitations of the list– Infinite number of ways to misspell drug names
• Does not try to resolve morphine vs. heroin– Morphine is the primary metabolite of heroin
An Example from NM Data
0
2
4
6
8
10
12
14
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
20
14
Death
s p
er
100,0
00
po
pu
lati
on
Drug Overdose Death rates for Selected Drugs, NM 1990-2014
Rx Opioid Heroin Methamphetamine Cocaine
Drug categories are not mutually exclusive2014 rates preliminaryRates age-adjusted to the US 2000 standard populationSource: Office of the Medical Investigator; UNM/GPS population
Top Rx Drugs in Overdose Death, NM 2014
0 20 40 60 80 100 120
oxycodone
hydrocodone
alprazolam
morphine
methadone
fentanyl
diazepam
Overdose death involvements
Deaths may involve more than one drugSource: NM Office of the Medical Investigator
An Example from Kentucky Data
0
50
100
150
200
250
300
2011 2012 2013 2014
Invo
lvem
en
ts
Selected Drugs Commonly Listed as Contributing to Kentucky Resident Drug Overdose Deaths, 2011-2014
Alprazolam Oxycodone Hydrodocone Fentanyl Heroin
2011-2014 data are provisional and subject to changeSource: http://www.mc.uky.edu/kiprc/programs/KVIPP/drug_overdose_deaths_00-14.pdf – Table 2Fentanyl increase in 2014 primarily due to illicit fentanyl
Level 3 Wrap up
• Literal text in death data can be useful for a variety of problems.
• Used experimentally with other data sources (ED, EMS)
• Epi tool available from CSTE website for SAS:
http://www.cste.org/members/group.aspx?id=87615
• Further development is possible to suit various needs.
– Includes cases where the source of the morphine was
listed as unknown on death certificate
T-Codes
Drug Category ICD-10 code
Benzodiazepines T42.4
Cocaine T40.5
Heroin T40.1
Methadone T40.3
Methamphetamine (Psychostimulants) T43.6
Other opioid analgesics
Natural and semi-synthetic opioid analgesics
(aka “Other opioids”)T40.2
Synthetic opioid analgesics, excluding
methadone (aka “other synthetic narcotics”)T40.4
Sensitivity
• Calculated the sensitivity of the death certificate to detect drug-specific poisoning deaths, using the toxicology results as the gold-standard:
• The sensitivity of death certificates were calculated separately for benzodiazepines, cocaine, heroin, methadone, and opioid analgesic-involved deaths.
** Methamphetamine compared in OR & King County, WA only.
Sensitivity of death certificate compared
to toxicology by jurisdiction
88%
95%92%
100%97%
100%
68%71%
61%
82%
91%
23%
71%
82%
91% 90%
107%
0%
20%
40%
60%
80%
100%
120%
Benzodiazepine Cocaine Heroin Methadone Methamphetamine Other OpioidAnalgesics
Perc
en
tag
e
WA (King County) NYC OR
Number of drug deaths with toxicology
missing from death certificates by jurisdiction
72 6
0 1 0
90
102
150
34
18
72
6
24
5 5 -5
-10
10
30
50
70
90
110
130
150
170
Benzodiazepine Cocaine Heroin Methadone Methamphetamine Other OpioidAnalgesics
Dif
fere
nc
e b
etw
ee
n t
ox
& d
ea
th c
ert
ific
ate
s
WA (King County) NYC OR
Level 4 Summary
• Benzodiazepines had the lowest sensitivity in the
three jurisdictions.
• Heroin sensitivity was second lowest.
• Sensitivity varied most widely for benzodiazepines.
• King County, WA had highest sensitivity of three
jurisdictions across all drug categories (except 107%
in OR – opioid analgesics).
Level 4 Conclusions
• Using death certificates alone results in underreporting
of drug-specific mortality rates.
• Important to note that using death certificates alone will
provide the number of drug poisoning deaths.
• Death certificate sensitivity varies by drug type and
jurisdiction.
Level 4 Conclusions
• Discordance between toxicology findings and literal
on death certificate, thus T-codes.
• Impact of F-codes on reporting drug poisoning
deaths– Why does “Acute and Chronic” not always get X(acute) code?
• Potential misclassification of Opioid Analgesic and
Heroin deaths
• Increasing concern about transitioning to heroin,
critical not to under report
Level 4 Implications
• Underestimation of drug-specific mortality on death
certificates can compromise effective targeting of
resources and public health interventions.
• Medical examiner/coroner information on drug-related
deaths could be systematically included in death certificate
cause-of-death documentation.
• There is no national standard to report drug poisoning
deaths. National standards could provide guidance for
drug-specific reporting and interpretation of toxicology
results.
Lessons Learned
Paper by members of CSTE Overdose
Recommendations & Lessons Learned for Improved
Reporting of Drug Overdose Deaths on Death
Certificates
Jennifer Sabel1, Ellenie Tuazon2, Denise Paone2, Svetla Slavova3,
Terry Bunn3, Dan Dao4, David Nordstrom5, Holly Hedegaard6
Affiliations: 1 Washington State Department of Health2 New York City Department of Health and Mental Hygiene3 Kentucky Injury Prevention and Research Center4 Kansas Department of Health and Environment5 Wisconsin Department of Health6 National Center for Health Statistics
Recommendations for epidemiologists
• Learn more about existing studies, methods and tools – Baseline state-to-state comparison of drug overdose deaths1
– Evaluation of the completeness and accuracy of the multiple cause-of-
death fields for drug overdose deaths2
– CSTE Overdose Subcommittee Epi tool
• Review your drug overdose data– CDC National Center for Injury Prevention and Control’s State Special
Emphasis Report (SER) Instructions for Drug Overdose Death Data
– Assess data quality • % of drug overdose deaths with unspecified drugs (T50.9, T40.6)
• % all deaths (not just drug overdose deaths) with an underlying cause of R99
• Collaborate with state vital statistics registrar • Share observations about the quality of the data from death certificates
on drug overdose deaths with their state vital statistics registrar
1. Warner M, Paulozzi LJ, Nolte KB, Davis GG, Nelson LS. (2013). State Variation in Certifying Manner of Death and Drugs Involved in Drug