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Examining Opioid and Heroin-Related Drug Overdose In health Center for Health and Environmental Data watch November 2016 No. 100 Office of eHealth and Data • Health Surveys & Evaluation Branch Examining Opioid and Heroin-Related Drug • Public Health Overdose in Colorado Informatics Branch Allison Rosenthal, MPH • Registries and Vital SAMHSA/CSTE Applied Epidemiology Fellow, Violence and Injury Prevention Statistics Branch - Mental Health Promotion Branch; Kirk Bol, MSPH Registries and Vital Statistics Branch; Barbara Gabella, MSPH Violence and Injury Prevention - Mental Health Promotion Branch. Background Nationally and in Colorado, opioid use disorders have emerged as a significant public health concern. Starting in the 1990s, opioid prescriptions (or, pain medications such as oxycodone, hydrocodone, and their combination with acetaminophen) began to rise nationwide partially due to the promotion of extended-release tablets and a change in prescriber culture to recognize the needs of patients with chronic pain (Okie, 2010). The dramatic increase in use has been associated with dependency, addiction, and other adverse health events including, but not limited to: heroin use disorders, spread of hepatitis infections and HIV, and fatal drug overdose (Bonhert et al, 2011; Garland et al, 2014; Paulozzi et al, 2006; Peters et al, 2016; Suryaprasad et al, 2014; and Young & Havens, 2011). The National Survey on Drug Use and Health estimates that from 2013-2014, 4.9 percent of the Colorado population of ages 12 years and older used prescription pain relievers non-medically (95% CI: 4.0-6.1%), which is similar to the national rate (4.1%, 95% CI: 3.9-4.2%). The Colorado Department of Public Health and Environment (CDPHE) is monitoring the severity of the epidemic using a variety of available data, including mortality data from death certificates registered in Colorado. This report will highlight trends in drug overdose deaths related to opioid use and heroin use and describe associated health disparities. Methods CDPHE’s Registries & Vital Statistics Branch manages the analysis of mortality data 4300 Cherry Creek Drive South collected through the registration of death certificates in Colorado. Mortality data Denver, Colorado 80246-1530 (303)692-2160 representing deaths among individuals who resided in Colorado from 2000-2015 (800)886-7689 were analyzed for this report. International Classification of Disease, 10th Revision (ICD-10) codes for underlying cause of death were used to identify drug overdoses, [email protected] using published definitions from the Centers for Disease Control and Prevention’s www.colorado.gov/cdphe National Center for Health Statistics, as shown in Appendix 1 population in each decedent’s census tract of residence (Chen et al, 2014; World Health Organization, 2016). Drug that is living at or below the federal poverty level (CDPHE, overdose deaths (also referred to as drug overdoses in this 2015). These population data come from the 2010-2014 five- report) were further classified according to manner (intent) year American Community Survey estimates made available of the overdose, including unintentional (accidental) by the U.S. Census Bureau. The poverty level categories and intentional self-harm (suicide). The report will also used in this report include 0-9.9 percent of the population describe the epidemiology of opioid-related and heroin- in a decedent’s community living at or below the federal related overdoses. Drug-type classifications were found poverty level, 10-19.9 percent, 20-29.9 percent and 30 in the multiple causes of death fields in death records. percent or greater. Counties in Colorado were categorized Deaths were classified as opioid-related if the individual into Health Statistics Region (HSR), a method often used to had a positive test for either semi-synthetic opioids (e.g. examine regional differences for various health indicators morphine, hydrocodone, oxycodone), methadone, or within Colorado and ensure that rates can be presented for synthetic opioids (e.g. fentanyl), and/or as a heroin-related rural and frontier regions with smaller populations. overdose if the individual had a positive test for heroin. If the record marked both, this death was counted in both Differences between rates are described as statistically opioid and heroin categories. significant if the 95 percent confidence intervals (95% CI) of two rates being compared do not overlap, or the p-value of All death rates are presented as deaths per 100,000 a formal comparison test is less than 0.05. population. Unless otherwise marked, all rates are age- adjusted to ensure comparability between occurrence of Results deaths over time, across geographic areas and between Trends by Time demographic groups. All age-adjusted rates were From 2000-2015, there have been 10,552 drug overdose computed using the direct method and applying the the deaths among Colorado residents with rates rising in 2000 U.S. Standard Population (Klein & Schoenborn, 2001). almost every year. In 2000, the number of overdose deaths was 351 and the age-adjusted rate was 7.8 deaths Drug overdoses were further examined for geographic per 100,000 population (95% CI: 7.0, 8.6). In 2015, there and demographic variability. Demographic characteristics were 880 deaths, and the rate increased to 15.7 (95% CI: explored include gender, age, race/ethnicity of the 14.6, 16.7). In nearly every year, Colorado’s rate of drug decedent, and area-based poverty. Area-based poverty overdose was significantly higher than the national rate. status is measured by calculating the percent of the Figure 1: Age-adjusted rates of drug overdose deaths in Colorado and in the U.S., 2000-2015. 18 Total drug poisoning (CO) 16 Total drug poisoning (US) 14 12 10 8 Age-adjusted rate per 100,000 per rate Age-adjusted 6 Opioid-related (CO) 4 Unspecified drug (CO) Heroin-related (CO) 2 Opioid & benzodiazepine-related (CO) 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Data Source: Vital Statistics Program, CDPHE; Centers for Disease Control and Prevention, National Center for Health Statistics. Underlying Cause of Death 1999-2014 on CDC WONDER Online Database. Drug-type categories are not mutually exclusive; cases are counted more than once if they were positive for multiple substances. 2 While Colorado’s drug overdose rates show signs of leveling from 2013 to 2015, the U.S. rates between 2012-2014 (the last year of data available at the national level) were still increasing. As seen in Table 1, opioid-related overdose deaths, which comprise a significant proportion of total drug overdose deaths, also rose dramatically in that fifteen-year period. Opioid-related overdoses tripled from 2000 (87 deaths; 1.9 per 100,000, 95% CI: 1.5-2.4) to 2015 (329 deaths; 5.8 per 100,000, 95% CI: 5.2-6.5) among Colorado residents, but also showed signs of stabilizing from 2013-2015. In that three-year period, the age-adjusted death rates were not significantly different and ranged from 5.4 to 6.1. Benzodiazepines (a family of prescribed medications used as sedatives and anxiety treatments) are often prescribed simultaneously with opioids and can increase the toxicity of opioids when taken concurrently (White & Irvine, 1999). Drug overdoses noting the presence of both substances doubled from 2013 to 2015 (36 deaths to 64 deaths), and the age- adjusted rate in 2015 was 1.2 (95% CI: 0.9, 1.2). Table 1: Age-adjusted drug overdose death rates per 100,000 in Colorado by drug type and other demographic categories, 2000 vs. 2013-2015. 2000 2013 2014 2015 Rate 95% CI Rate 95% CI Rate 95% CI Rate 95% CI Drug Type (a) Total poisoning deaths - US 6.2 (6.1, 6.3) 13.8 (13.7, 13.9) 14.7 (14.5, 14.8) N/A N/A Total poisoning deaths - CO 7.8 (7.0, 8.6) 15.4 (14.3, 16.5) 15.8 (14.7, 16.8) 15.7 (14.6, 16.7) Colorado Specific Opioid-related 1.9 (1.5, 2.4) 5.4 (4.8, 6.0) 6.1 (5.4, 6.8) 5.8 (5.2, 6.5) Heroin-related 0.8 (0.5, 1.1) 2.2 (1.8, 2.7) 2.8 (2.4, 3.3) 2.9 (2.5, 3.4) Opioid & benzodizeipine-related 0.2 (0.1, 0.4) 0.6 (0.4, 0.9) 1.2 (0.9, 1.5) 1.2 (0.9, 1.5) Unspecified 1.2 (0.9-1.5) 1.1 (0.8, 1.4) 0.7 (0.5, 0.9) 0.5 (0.3, 0.7) Manner of death Accidental 4.8 (4.2-5.5) 11.1 (10.2, 12.0) 12.0 (11.1, 13.0) 12.7 (11.8, 13.7) Suicide 1.3 (1.0, 1.7) 3.4 (2.9, 3.9) 3.0 (2.5, 3.5) 2.5 (2.0, 2.9) Undetermined manner/intent 1.6 (1.2, 1.9) 0.9 (0.6, 1.1) 0.7 (0.5, 1.0) 0.5 (0.3. 0.7) Sex Male 10.0 (8.7, 11.4) 16.8 (15.3, 18.4) 18.2 (16.6, 19.8) 18.8 (17.2, 20.5) Female 5.5 (4.5, 6.4) 13.9 (12.5, 15.3) 13.2 (11.8, 14.6) 12.4 (11.1, 13.8) Age-specific rates by category (b) 15-24 3.2 (1.8, 4.7) 12.7 (10.1, 15.3) 9.4 (7.1, 11.6) 8.4 (6.4, 10.5) 25-34 10.5 (8.0, 12.9) 21.4 (18.1, 24.7) 25.1 (21.5, 28.7) 28.0 (24.2, 31.7) 35-44 16.8 (13.9, 19.8) 21.8 (18.4, 25.2) 25.4 (21.7, 29.0) 24.2 (20.7, 27.8) 45-54 15.1 (12.0, 18.1) 29.4 (25.4, 33.3) 28.5 (24.6, 32.4) 27.8 (24.0, 31.7) 55-64 5.8 (3.3, 8.4) 22.9 (19.2, 26.5) 23.7 (20.1, 27.4) 23.2 (19.6, 26.7) 65 & older 4.3 (2.3, 6.3) 9.6 (7.2, 12.0) 8.4 (6.2, 10.6) 8.1 (6.0, 10.2) Race Non-Hispanic White 7.5 (6.6, 8.4) 16.9 (15.6, 18.2) 17.0 (15.7, 18.3) 16.7 (15.4, 18.0) Hispanic/Latino(a) 10.0 (7.5, 12.6) 12.4 (10.1, 14.7) 13.3 (10.9, 15.6) 14.2 (11.8, 16.5) Black/African American 9.7 (5.0, 14.3) 13.5 (8.8, 18.3) 17.3 (11.9, 22.8) 13.6 (9.0, 18.1) Asian/Pacific Islander N/A N/A 5.7 (2.8, 9.6) 4.0 (1.7, 7.3) 4.7 (2.2, 8.2) American Indian 8.0 (2.6, 16.3) 10.9 (5.2, 18.8) 20.1 (11.0, 29.2) 10.4 (4.9, 17.8) Data Source: Vital Statistics Program, CDPHE; Centers for Disease Control and Prevention, National Center for Health Statistics.
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