Prescription Drug O Overdose d Deaths D th iin New N Mexico

Michael Landen, MD, MPH State Epidemiologist New Mexico Department of Health

25.0 20.0 15.0 NM 10.0

US

5.0 0.0

199 90 199 91 199 92 199 93 199 94 199 95 199 96 199 97 199 98 199 99 200 00 200 01 200 02 200 03 200 04 200 05 200 06 200 07 200 08 200 09 201 10 201 11

Age Adjusteed Rates per 100,000  persons

30.0

Drug Overdose Death Rates, New Mexico and United  States, 1990‐2011

Source: 1990-2008: CDC Wonder; 2009 US: NCHS; 2009-2011 NM: BVRHS.

Drug Overdose Death Rates Leading States, U.S., 2009 Rank 1 2 3 4 5

State New Mexico Oklahoma Nevada Utah Alaska US

Sources: CDC Vital Signs Rates are age-adjusted to the 2000 US Standard Population.

Deaths per 100,000 22.4 20 9 20.9 20.6 18.7 18 1 18.1 12.0

Drug Overdose Death Rates, 2009 14.3

4.6

14.8

12.8 7.9

12.8 11.7

20.6 10.8

11.3

6.0 18.7

15.5

14.8

22.4

11.1 20.9

99 9.9 10.2

18.1

10.9

6.7

7.9

14.3 7.2 10.7 14.1 14.5

15.2

10.8 12.6

17.9

12.8

15.1

13.4

12.6 13.2

11.3 13.8

8.6

10.2

16.9

NH 12.4 VT 8.3 MA 12.0 RI 14.7 CT 11.1 NJ 3.0 DE 15.5 MD 12.5 DC 3.9

U.S. Rate 12.0

3.0-10.9 11.0-14.2 14.3-22.4

SOURCE: CDC Wonder.

Age-adjusted d rates per 100,,000 persons

Drug Overdose Death Rates by Manner New Mexico and U.S., 2001-2011 30.0 25.0 20 0 20.0 15.0 10.0 5.0 0.0 2001

2002

2003

2004

Unintentional

2005

2006

Suicide

2007

2008

Undetermined

Source: New Mexico Vital Records and Health Statistics; CDC Wonder.

2009 US

2010

2011

Leading Causes of Unintentional Injury Death, New Mexico, 2001-2011 Age-adjusted rates per 100,000 persons

30.0

25.0

20.0

15.0

10 0 10.0

5.0

0.0 2001

2002

2003

2004

Poisoning

2005

2006

2007

Motor Vehicle, Traffic

Source: New Mexico Vital Records and Health Statistics.

2008 Falls

2009

2010

2011

Unintentional Overdose Death Rates by Type of Drug, New Mexico, 19901990-2010 Deathss per 100,00 00 persons

25 20 15 10 5 0

Any Illicit Drug

Any Prescription Drug

Note: Groups are not mutually exclusive Data Source: The New Mexico Office of the Medical Investigator Rates are age-adjusted to the 2000 US Standard Population.

Unspecified

Total

Most Common Drugs g Causing g Unintentional Drug g Overdose Death, New Mexico, 2008-2010 2008

AA Rate

2009

AA Rate

2010*

AA Rate

Heroin

7.8

Heroin

6.1

Unspecified

5.7

Cocaine Coca e

5.3 5 3

Cocaine Coca e

4.6 6

Heroin e o

3.8 3 8

Oxycodone

3.1

Oxycodone

3.9

Cocaine

2.8

Methadone

2.8

Alprazolam

2.9

Oxycodone

2.7

Alprazolam

2.2

Diazepam

2.3

Morphine

1.6

Diazepam

22 2.2

Morphine

21 2.1

Methadone

15 1.5

Most Common Drugs Causing Unintentional Hydrocodone 2.2 MA 1.8 Mexico, Alprazolam Drug Overdose Death, New 200820081.5 2010 Unspecified 17 1.7 Unspecified 18 1.8 MA 15 1.5 * 2010 rate declines by drug type are partly a function of decreases in specificity of drug type coding Source: The New Mexico Office of the Medical Investigator Notes: Rates are not mutually exclusive. Rates are age-adjusted to the 2000 US Standard Population.

Drug Overdose Death Rates by County, County New Mexico, 2007-2011 and U.S., 2009 Rio Arriba Sierra San Miguel Grant Bernalillo Valencia Eddy Taos Torrance Socorro Santa Fe Colfax New Mexico Lincoln Chaves Otero Lea Sandoval Dona Ana San Juan Los Alamos McKinley Luna Cibola U.S. 0.0

10.0

20.0

30.0

40.0

50.0

Age-adjusted rates per 100,000 persons

Source: BVRHS; CDC Wonder.

60.0

70.0

Source: BVRHS.

Male Female 85+

75-84 7

65-74 6

55-64 5

45-54 4

35-44 3

25-34 2

20-24 2

18-19 1

15-17 1

5-14

0-4

85+

75-84 7

65-74 6

55-64 5

45-54 4

35-44 3

25-34 2

20-24 2

18-19 1

15-17 1

5-14

0-4

Rates per 1000,000 pe R ersons

Drug g Overdose Death Rates by y Age, g , Sex,, and Race, New Mexico, 2007-2011 90

80

70

60

50

Native American

40

Hispanic

30

White

20

10

0

Prescription Opioid Drug Sales by Weight (Grams) in the DEA* Database, New Mexico, 2002-2011 1,400,000 1,200,000 1,000,000 800,000 600,000 400,000 200,000 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 * Drug Enforcement Administration, U.S. Dept. of Justice.

Prescription Opioid Drug Sales by Weight (Grams) in the DEA* Database, New Mexico, 2002-2011 600,000.00 500,000.00 OXYCODONE 400,000.00

HYDROCODONE MORPHINE CODEINE

300,000.00

METHADONE MEPERIDINE

200,000.00

BUPRENORPHINE HYDROMORPHONE

100,000.00

FENTANYL 0.00 2001

2002

2003

2004

2005

2006

2007

2008

* Drug Enforcement Administration, U.S. Dept. of Justice.

2009

2010

2011

Oxycodone Sales Rate by 3-Digit Zip Codes New Mexico, Mexico 2011 874

873

875

884 877

870

State Rate: 2.6

871

881 878 879

883 882

2.9 2.0 1.3 0.9

– – – –

4.5 2.8 2.0 1.2

Kg/10,000 population

880

Source: Data-Drug Enforcement Administration, U.S. Dept. of Justice. Pop-U.S. Census Bureau.

Oxycodone Sales Rate by 3 3-Digit Digit Zip Codes New Mexico, 2011 5.0 45 4.5 4.0 3.5 3.0 2.5

4.5 3.4

3.1

2.8

2.8

Rates R t are Kg/10,000 population

2.6

20 2.0 1.5 1.0 0.5 0.0

Source: DEA, U.S. Dept. of Justice; U.S. Census Bureau.

2.0

2.0

1.9 1.4

1.2

1.1

1.0

0.9

Prescription Total Opioid and Oxycodone Sales Ratios United States and New Mexico, 2001-2011 7.0

Ratio o of Kg per 10,00 00 persons

60 6.0

5.0

4.0

NM Opioid US Opioid

3.0

NM Oxycodone US Oxycodone y

2.0

1.0

0.0 2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

* 2011 NM ratio based on 2010 population estimate. SOURCE: Sales data: DEA, U.S. Dept. of Justice; Pop estimates from BBER, UNM and U.S. Census Bureau.

2011*

Drug Overdose Death Rate and OPR Sales Rate New Mexico, 2001-2011 30 0 30.0

80 8.0

Deaths per 100,00 00

6.0 20 0 20.0

5.0

15.0

4.0 3.0

10.0

5.0

drug deaths/100,000

2.0

opioid sales kg/10,000

1.0

0.0

0.0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Source: BVRHS, NMDOH; ARCOS, DEA.

Sale es kg per 10,00 00

7.0

25.0

Drug Overdose Death with Numbers of Prescribers and Pharmacies Number of

Case Control Odds Mean Mean Ratio for increase of one

95% CL

Prescribers

3.0

1.4

1.7

1.6-1.9

Pharmacies

2.4

1.2

2.3

2.0-2.5

Paulozzi LJ, Kilbourne EM, Shah NG, Nolte KB, Desai HA, Landen MG, Harvey W, W Loring LD. LD A history of being prescribed controlled substances and risk of drug overdose death. Pain Med. 2012 Jan;13(1):87-95.

Number of Prescribers per Patient with Risk of Unintentional Drug Overdose Death New Mexico, October, 2006— 2006—March, 2008

Paulozzi LJ, Kilbourne EM, Shah NG, Nolte KB, Desai HA, Landen MG, Harvey W, Loring LD. A history of being prescribed controlled substances and risk of drug d d h

Past 30-day Painkiller Use to Get High Grades 9-12, NM, 2007-2011 100

NM

Perce ent (%)

80

60

40

20

11.7

14.3

11.3

0 2007

2009

Source: NM Youth Risk and Resiliency Survey (YRRS), NM DOH and PED

2011

NM rate – no trend

Ever Used a Prescription Drug without a Doctor's Doctor s Prescription Grades 9-12, NM and US, 2011 100

NM US

Percen nt (%)

80

60

40

20

20.7

20.2

0 2011

Source: NM Youth Risk and Resiliency Survey (YRRS), NM DOH and PED

Only one year of data available

Nonmedical Use of Pain Relievers in Past Year by Age Age, NM and US, US 2008-2009 2008 2009

Source: NSDUH

Drug Overdose Hospital Inpatient Discharge Rates by Sex, New Mexico, 2001-2010

Age-adjusted rate per 10,000 persons

16.0 14.0 12.0 10.0 Male

8.0

Female Total

6.0 4.0 20 2.0 0.0 2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

NOTE: Drug overdose deaths based of the following external ICD ICD-9 9 codes: E850 E850-E858; E858; E950.0 E950.0-E950.5; E950.5; E962.0; E980.0 E980.0-E980.5. E980.5. Data include hospital discharges from in-state, non-federal hospitals (IHS not included). SOURCE: New Mexico Department of Health, Hospital Inpatient Discharge Data.

Drug Overdose Hospital Inpatient Discharge Rates by County, New Mexico, 2008-2010 Average Grant San Miguel Rio Arriba Hidalgo Colfax Mora Eddy Chaves Guadalupe Sierra Luna Roosevelt S t Fe Santa F Taos San Juan NM Dona Ana Socorro Otero Curry Bernalillo Lincoln Lea Torrance Los Alamos Valencia Sandoval Cibola McKinley 0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

NOTE: Rates are age-adjusted based of the following external ICD-9 codes: E850-E858; E950.0-E950.5; E962.0; E980.0-E980.5. Data include hospital discharges from in-state, non-federal hospitals (IHS not included). SOURCE: New Mexico Department of Health, Hospital Inpatient Discharge Data.

Drug Overdose Emergency Department Rates by County, New Mexico, 2010 Sierra Quay Socorro Grant Bernalillo Los Alamos Chaves Rio Arriba NM Valencia Torrance o a ce Cibola San Juan Sandoval Otero Santa Fe Roosevelt McKinley Dona Ana Curry Eddy Taos Lea San Miguel

Rates were calculated based on the following ICD-9 external cause codes: E850-E858; E950.0-E950.5; E962.0; E980.0-E980.5.

0.0 50.0 100.0 150.0 200.0 250.0 300.0 350.0 400.0 450.0 NOTES: Data are submitted by individual hospital emergency departments which have varied databases, capacities to extract data d and d ffile l fformats that h are produced. d d C Coding d within h the h dataset d may not be b uniform. f Currently C l limited l d quality control or assurance efforts are in place. Data submitted have been examined for internal consistency and to determine whether they have conformed to the NMDOH request guidelines.

Drug Withdrawal Syndrome in Newborns New Mexico, 2000-2011

Per 1,000 1 000 Live Births

7.0 60 6.0

6.2

5.0 40 4.0

44 4.4 3.8

3.0

3.2

20 2.0 1.0

2.1 1.7

1.5

1.7

1.9

1.6

3.3

1.9

0.0

NOTE: Data include hospital discharges from in-state, non-federal hospitals (IHS not included) for both primary and secondary diagnoses. SOURCE: New Mexico Department of Health, Hospital Inpatient Discharge Data.

NM DOH Activities     

Advisory Council Surveillance Community Overdose Prevention Buprenorphine Inpatient p Treatment

Advisory Council    



Established E t bli h d by b SB 215 Chaired by Secretary of Health Appointed by Governor Includes licensing board, professional association pain management, association, management and consumer representatives Focusing on recommendations to reduce prescription drug overdose and improve pain management

Cumulative C l ti Number N b off States St t Authorizing A th i i Prescription Drug Abuse-related Laws by Type of Law,, United States,, 1970-2010

Source: CDC.

S Surveillance ill       

Deaths D th Hospitalizations Emergency Department Visits Neonatal Drug Withdrawal Opioid Sales Prescriptions Special studies ◦ Falls ◦ Diversion

evidence-based One evidence based approach DOH is working with communities to establish modified pilots across the state.

C Community it Overdose O d Prevention P ti

• • • • • • •

DOH is working with groups in these communities to implement Project Lazarus style interventions: Albuquerque Taos Truth or Consequences Santa Fe Gallup Roswell Alamogordo g

Buprenorphine 

DOH p provides o ides $240 $240,000 000 to support s ppo t 3 projects

  

Albuquerque – 111 patients Santa Fe – 25 patients Las Cruces – 293 patients



Most patients do not complete the 66 month program

Inpatient Treatment 

T Turquoise i Lodge L d iin Albuquerque Alb ◦ Currently 34 adult beds – medically managed withdrawal and 30 days intensive inpatient rehabilitation – 635 patients ◦ Planned 20 adolescent beds – tentative start F b February 2013



Other ◦ Roswell Rehabiliation – 28 beds, beds 298 patients ◦ Fort Bayard (Yucca Lodge) – 18 beds, 110 pts

Conclusions • •

• •

NM drug overdose death rate highest in nation ti Prescription drug overdose deaths are now more common than illicit drug overdose deaths High rates are now more distributed throughout NM Prescription p opioid p sales in NM now greater than in U.S.

Recommendations   

 

Use PMP data U d t to t track t k and d reduce d misuse i and inappropriate prescribing Licensing boards should strengthen rules Increase community overdose prevention by providing naloxone with opioid prescriptions Have Council p provide overdose p prevention recommendations by end of year Assess and address treatment need

Thanks to the following individuals working in Substance buse Epidemiology p de o ogy at DOH O for o Abuse their efforts: Brad Whorton Jim Davis Melissa Heinz Jim Roeber