Transcript Presentation: Karl Williams, MD, MPH

The Overdose Crisis:
View from Allegheny County
Karl E. Williams MD MPH
Chief Medical Examiner
Allegheny County
ACOPC
Summer Conference
July 30, 2015
CDC - July 25, 2015
http://www.cdc.gov/vitalsigns/heroin/
New News or Old?
Unintentional Drug Overdose Deaths
in U.S. during 1999-2007
Opiate and Heroin
Opiates and Opioids
Heroin
Why
Florida Experience
Number of prescriptions
Heroin deaths
OD vs other Causes
More Old News
Why
Heroin Cost
Allegheny County
OD Death vs Rx
ODs by “Rural Status”
Ohio
Crude rates for drug overdose deaths and drug
misuse-or abuse-related emergency department visit
among women by select drug class
Snapshot - Europe
Heroin overdoses kill two in Pittsburgh area; others revived with Narcan
Wednesday, April 15, 2015
Tribune Review
Two people are dead in the largest wave of
heroin overdoses in the Pittsburgh area since a
fentanyl-laced batch killed almost two dozen in
2014, officials said.
The Allegheny County Crime Lab is analyzing the
stamp bags.
ACOME Drug Deaths as % of
Morgue and Accidental Cases
80.00%
67.64%
70.00%
64.51%
60.00%
56.63%
57.77%
58.06%
63.33%
60.37%
50.00%
40.00%
30.00%
25.40%
20.80%
20.00%
18.99%
19.62%
22.18%
23.58%
21.30%
10.00%
0.00%
2008
2009
2010
Drug Death as % Accidental Deaths
2011
2012
Drug Death as % All Morgue Cases
2013
2014
ACOME Drug Deaths Total
Single or Combined
Case
Year
Total Drug
Deaths
1 Drug
2 Drug
3 Drug
4 Drug
5 Drug
6 Drug
7 Drug
2012
288
111
78
59
27
11
1
1
2011
262
89
72
57
27
12
2
3
2010
227
61
69
52
28
9
1
7
2009
223
52
57
61
24
20
3
6
2008
235
81
56
58
22
13
2
3
ACOME Accidental Overdose Cases
2014 Top 8 Drugs Found
Single or Combined OD
Methadone, 20
Oxycodone, 23
Heroin, 138
Morphine, 27
Heroin
Cocaine
Alcohol
Alprazolam, 34
Fentanyl
Alprazolam
Morphine
Oxycodone
Fentanyl , 42
Methadone
Alcohol, 55
Cocaine, 71
Top Eight Drugs Found in Overdose Deaths
2014 Top 8 Drugs Found
2013 Top 8 Drugs Found
Single or Combined OD
Single or Combined OD
Methadone,
20
Heroin
Oxycodone, 23
Heroin, 138
Morphine, 27
Cocaine
Alcohol
Morphine, 20
Hydrocodone,
26
Oxycodone,
35
Codeine, 18
Heroin
Heroin, 146
Fentanyl
Alprazolam, 34
Alprazolam
Fentanyl, 42
Morphine
Cocaine, 71
Methadone
Cocaine
Alprazolam
Alprazolam,
39
Oxycodone
Hydrocodone
Oxycodone
Alcohol, 55
Alcohol
Morphine
Cocaine, 67
Alcohol, 81
Codeine
2012 Top 8 Drugs Found
2011 Top 8 Drugs Found
Single or Combined OD
Single or Combined OD
Oxymorphone,
26
Oxycodone, 31
Methadone, 22
Heroin
Heroin, 140
Alcohol
Morphine, 24
Diazepam, 25
Methadone,
26
Heroin, 95
Cocaine
Cocaine
Morphine, 31
Alprazolam
Morphine
Alprazolam, 36
Cocaine, 68
Alcohol
Alprazolam,
42
Oxycodone
Alprazolam
Oxycodone
Oxymorphone
Alcohol, 73
Methadone
Heroin
Methadone
Cocaine, 83
Oxycodone,
51
Diazepam
Morphine
Alcohol, 60
Misclassification of Morphine Deaths
• Heroin undergoes rapid breakdown to 6MAM and
then to morphine
• Heroin has a half-life of 9 minutes, and 6 MAM 39
minutes
• Morphine has a longer half-life (1.3-6.7 hours),
and therefore depending on survival time might
be the only drug detected
• In the absence of a drug history, stamp bags, or
track marks, some heroin deaths may be
classified as morphine deaths
Fentanyl
•
•
•
•
•
Fentanyl is an opioid analgesic.
First synthesized by Janssen Pharmaceuticals in the late 1950’s.
High potency with a short duration of action.
Fentanyl is 100x more potent than morphine.
Therapeutic Uses
– Utilized in surgical procedures as pre-anesthetic, primary anesthetic and for
post surgical anesthesia
– Management of chronic pain
• Transdermal patch (Duragesic)
– Breakthrough pain in cancer patients
• Oral transmucosal fentanyl
• Actiq (fentanyl lollipops), Fentora (Buccal tablets)
Duragesic Patch
• Transdermal patch
• Fentanyl lipophilic, readily absorbed through
skin, releasing drug to blood stream for 72
Drug Reservoir
hours. Backing
• Allows for long lasting pain relief. Release Membrane
ADHESIVE
Protective Membrane
Duragesic Patch:Illicit Uses
• Patches are abused by removing gel from package
and injecting, smoking or ingesting contents.
• Patches may be frozen, cut into pieces and placed
under tongue or in the cheek cavity for
transmucosal absorption.
• Used patches abused due to the presence of a
large percentage of fentanyl remaining in patches
after 3 days of use.
Illicit Fentanyl Analogs/ Designer Drug
• 1979
– Clandestine lab in California synthesized alphamethyl fentanyl
– Distributed it as a heroin substitute under the
name “China White”
– Coined the term “Designer Drug”
“Designer Drug”
• Gary L. Henderson, professor at University of
California School of Medicine, Dept. of
Pharmacology
• Defined “Designer Drug” as:
–
–
–
–
–
–
Synthetic drug of abuse
Analog of the pharmaceutical fentanyl
Illicit laboratory producing an original drug
Not an illicit copy of the pharmaceutical
No clinical evaluations in humans
Not listed on DEA list of restricted drugs
California Designer Drug Outbreak
(1979-1984)
• 1979
– α-methylfentanyl
• 1984
– α-methylacetylfentanyl
• 1984
– 3-methylfentanyl
• Cis isomer: 6000x
morphine
• Trans isomer: 400x
morphine
• Overall identified 10 illicit
analogs
• Extremely potent!!
Fentanyl
Fentanyl Outbreak 1: 1988
• Emergency room at AGH and County Coroner (Dr. Perper) identified cases
clinically consistent with overdose.
– No detectable levels of common drugs of abuse.
– Undercover narcotics agents purchased street drugs and submitted them to the
lab.
– Identified 3–methylfentanyl (TMF): 400x Morphine potency
– Total number of deaths: 16 cases
•
First instance of a designer drug outbreak outside of California
– Calgon Chemist – Thomas Schaefers (47) responsible for the synthesis of 3methylfentanyl
• Synthesis began in fall of 1987
– Distributor:
• Cooperated with authorities
• Received 11 years
– Schaefers:
• Sentenced to 40 years
Outbreak 1: 1988
•
•
•
•
Median Age: 36 (19-44)
Males (88%)
Most had prior history of drug abuse
Multiple drugs besides TMF were identified in
blood and tissues specimens (median 3 drugs)
• 13 cases: cocaine or nonfentanyl opiates
• 7 cases: morphine
Outbreak 2: 2006
• CDC/DEA surveillance system reported 1013 confirmed
nonpharmaceutical fentanyl (NPF) deaths
– Outbreaks of fentanyl overdoses and deaths in Delaware, Illinois, PA, NJ, Michigan and
Minnesota
– In 2007 DEA listed N-phenethyl-4- piperidone (NPP), a precursor chemical used by
clandestine labs to illicitly manufacture fentanyl as a List 1 chemical
– Distributor: New Jersey
• 27 Deaths in Allegheny County attributed to fentanyl alone or in
combination with heroin.
– Occurred from 4/23/06-7/24/06
– Fentanyl was being packaged and sold on street in same manner as
heroin.
Clandestine Manufacture:
April 2005-March 2007
• CDC/DEA surveillance system reported 1013
confirmed nonpharmaceutical fentanyl (NPF)
deaths
• In 2007 DEA listed N-phenethyl-4- piperidone
(NPP), a precursor chemical used by
clandestine labs to illicitly manufacture
fentanyl as a List 1 chemical
Outbreak 2: 2006 (cont.)
• Drug Stamp Bags submitted to lab:
– ≈100 Stamp Bags
• 50% contained fentanyl only
• 50% contained fentanyl combined with heroin
– Bags identified with Stamps:
•
•
•
•
•
•
“Get High or Die Trying”
“Burn Out”
“Way to go/Don diva”
“Tiffany”
“Fendi”
“Truth”
Outbreak 3: 2014
• Short Duration – 2
weeks
• Pittsburgh Post Gazette:
February 1, 2014
– “Tests confirm fentanyllaced heroin led to 14
overdose deaths in
Allegheny County.”
Outbreak 3: 2014 (cont.)
• Law Enforcement:
– Local – Pittsburgh Narcotics
– State – Attorney Generals Office
– Federal – US Drug Enforcement Agency
• All worked overtime and set up tip-lines in an
effort to get the potent heroin off the streets.
• Efforts worked: Only 1 cases involving fentanyl
since January 31, 2014
Outbreak 3: 2014
• ACOME: Rash of overdose deaths in two week period
(1/16-1/29).
• Stamp bags submitted in Death Investigation marked
“Theraflu” and “Bud Ice.”
• Expedited testing of stamp bags revealed presence of
heroin and fentanyl.
• Expedited ELISA screening of blood revealed
presumptive positive results for opiates and fentanyl.
Overdose crisis in Southwest PA
• Friday – January 24
– Three “Probable” ODs in autopsy room
– Outlier for ODs
– Fentanyl ordered from Drug Chemistry was positive
• Saturday – January 25
– All four cases obvious drug overdoses
• Sunday – January 26
– Three of five cases obvious drug overdoses
• Tuesday/Wednesday
– Pure white powder composed of 50/50 Heroin and fentanyl found in
both evidence from death scenes and in seized material from drug
busts
– Powder identified in only two the multitude of stampbags
– Prominent peaks of heroin and fentanyl identified in the blood of
overdose victims.
January 2014
Before and after Jan 16
COR #
14-0073 1/4/14
LAB #
14-00120
Age
29
Gender
FEMALE
WHITE
14-0128 1/6/14
14-00217
24
MALE
WHITE
14-0282 1/11/14
14-00347
26
MALE
WHITE
14-0296 1/12/14
14-0430
29 FEMALE
WHITE
Preliminary TOX Results
Race
CARRICK
CPR,BUTLER
JEFF.HILLS
UNKNOWN
HARRISON TWP
PASSION
MT. WASHINGTON
Opiate pos
Opiate pos
Opiate pos
Opiate pos
14-0296 1/12/14
14-00431
43
MALE
WHITE
14-0340 1/13/14
14LAB00465
70
MALE
BLACK
TUNAFISH
GLASSPORT
UNKNOWN
E. PITTSBURGH
Opiate pos
Opiate pos
14-0412 1/16/14
14LAB00568
29
MALE
WHITE
14-0414 1/17-14
14LAB00570
26
MALE
WHITE
14-0478 1/18/14
14LAB00591
48
FEMALE
BLACK
14-0493 1/19/14
14LAB00589
25
FEMALE
WHITE
POKER
E. LIBERTY
MULTIPLE – BUD ICE, PASSION,
INCOME TAX, GORILLA, see story
for more
Opiate pos
Fentanyl pos
WEST END
UNKNOWN
DOWNTOWN
GUCCI, DIESEL, LSI
Opiate pos
Fentanyl pos
WEST END
LUCKY CHARMS
Opiate pos
Fentanyl pos
Opiate pos
Fentanyl pos
January 19-25
14-0493 1/19/14
14LAB00589
14-0519 1/20/14
14LAB00686
14-0537 1/21/14
14LAB00716
14-0565 1/22/14
51 MALE
WHITE
48
MALE
WHITE
14LAB00761
31
MALE
WHITE
WEST END
LUCKY CHARMS
PENN HILLS
GREEN LIGHT
ASPINWALL
BUD ICE
THERAFLU
14-0582 1/23/14
14LAB00764
50
MALE
WHITE
SQUIRRELL HILL
14-0583 1/23/14
14LAB00765
26
MALE
WHITE
14-0620 1/24/14
14LAB00801
46
MALE
WHITE
14-0600 1/23/14
14LAB00798
45
MALE
WHITE
14-0592 1/23/14
14-0632 1/25/14
14-0655 1/25/14
14LAB00797
14LAB00802
14LAB00820
25
46
30
36
FEMALE
FEMALE
FEMALE
MALE
WHITE
WHITE
WHITE
WHITE
THERAFLU
BELTZHOOVER
NO STAMP
E. LIBERTY
UNKNOWN STAMP
TARENTUM
THERAFLU, LIFE SUPPORT,
DIESEL, BUD ICE, CHECK MATE,
TOM FORD
PENN HILLS
MAGIC CITY
BUD ICE,
TROY HILL
INCOME TAX, DR. PEPPER, BEST
BUY
BLOOMFIELD
THERAFLU
Opiate pos
Fentanyl pos
Opiate pos
Opiate pos
Fentanyl pos
Opiate pos
Fentanyl pos
Opiate pos
Fentanyl pos
Opiate pos
Fentayl pos
Opiate pos
Fentayl pos
Opiate pos
Fentayl pos
Opiate pos
Fentayl pos
Opiate pos
Fentayl pos
Opiate pos
Fentanyl pos
Before and after January 25
14-0655 1/25/14
14LAB00820
36
MALE
WHITE
BLOOMFIELD
THERAFLU
CASTLE SHANNON
Opiate pos
Fentanyl pos
14-0658 1/25/14
14LAB00819
29
MALE
WHITE
14-0704 1/27/14
14LAB00905
46
FEMALE
WHITE
Opiate pos
Fentanyl ND
WHITE
BUD ICE
KNOXVILLE
MAGIC CITY
GREENTREE CITY
14-0753 1/29/14
14LAB01001
40
MALE
14-0802 1/31/14
14LAB01037
30
MALE
WHITE
CVS
BLOOMFIELD SCORPION
14-0943 2/6/14
14LAB01248
51
FEMALE
WHITE
OAKMONT THERAFLU
Fentanyl ND
Opiate ND
14-1018 2/9/14
14LAB01324
54
MALE
WHITE
NORTH SIDE TOTAL
CONTROL
Fentanyl ND
Opiate pos
14-1043 2/10/14
14LAB01422
23
MALE
WHITE
MONROEVILLE
Fentanyl ND
Opiate pos
14-1138 2/13/14
14LAB01452
42
MALE
WHITE
BELTZHOOVER
UNMARKED
Pending
14-1232 2/16/14
14LAB01490
24
MALE
WHITE
NORTHSIDE SPARTICUS
PENDING
14-938
2/6/2014
14LAB01247
43
MALE
BLACK
Opiate pos
Fentanyl pos
OPIATE POS
FENTANYL ND
OPIATE POS
FENTANYL ND
Fentanyl ND
Opiate pos
Stamp bags –
seized and from death scenes
Bud Ice
Theraflu
Some final thoughts - 1
• What is Old is only historical interest. It can
provide lessons, but cannot dictate public
policy for a situation that is rapidly changing
and inevitably has a unique quality at the local
level.
– Hence the importance of the availability of those
dealing with the problem to apply LOCAL
knowledge of the drugs in one particular area
Some final thoughts - 2
• Incredible complexity of Forensic Toxicology and the Tox report
– OMEAC has a full-time Forensic Toxicologist to help with the almost
300 cases a year – and only one report format to deal with!
• Sampling of 4+ sites
• Post-mortem redistribution
• Ante and post mortem redistribution
• Issue of POST-MORTEM drug levels versus levels in the living!!!
• Coroners and Medical Examiners System – PA
– Available resources – limited
• Westmoreland vs. Clarion
– No standardization of the Death Certificate
• List of drugs vs. “Combined Drug Toxicity
The Future
• Expand participating counties
– Begin to develop a picture of SW Pennsylvania –
PEMA Region 13
– Provide support to local communities through
identification of resources and specifics of local
OD problem
• A drug overdose dataset the includes LEVELS
or drugs and metabolites
• Provide Forensic Toxicology support for efforts
Thank You
?
• Acknowledgments
– Jennifer Jansen and the Toxicology Division
– Joshua Yohanna and the Drug Chemistry Division
– Patria Reikel– Department of Computer Services
• Allegheny County Overdose Prevention Coalition
– http://www.overdosefreepa.pitt.edu/