Highlight on Ohio: CDC reports on risk factors for unintentional fentanyl overdose deaths

The Ohio Department of Health (ODH) announced that the Centers for Disease Control and Prevention (CDC) issued a report examining the increase in unintentional fentanyl-related drug overdose deaths in Ohio. ODH requested CDC’s assistance in September 2015 after 2014 drug overdose data showed that Ohio’s fentanyl-related overdose deaths increased from 84 in 2013 to 502 in 2014, a 500 percent increase. Preliminary data also indicated that the number of fentanyl-related deaths in Ohio was continuing to increase in 2015.

Fentanyl-related deaths in Ohio also accounted for 20 percent of all drug poisoning deaths in 2014, a substantial increase over the 4 percent in 2013. According to a CDC Health Alert Network advisory, Ohio also ranked number one in the nation in total fentanyl seizures in 2014, with 1245 compared to the second ranked state, Massachusetts, which had a total of 630 seizures.

Ohio’s Public Health Response

The ODH has launched a comprehensive response to the increase in fentanyl-related deaths. A broad overview of these activities can be found on the Ohio Mental Health and Addiction services website.  They include: (1) investment of $1 million over the fiscal years 2016-2017 to expand access to naloxone (a medication used to block the effects of opioids, especially in overdose) through local health departments; (2) growth of the governor’s Start Talking! initiative to continue efforts to prevent drug use before it starts; (3) increased functionality of prescription drug monitoring through improvements in the usability of Ohio’s Automated Rx Reporting System (OARRS); and (4) continued work with communities to enhance local efforts through the Health Resources Toolkit for Addressing Opioid Abuse.

CDC Assistance Sought

As part of its public health response, the ODH also requested CDC’s assistance in an epidemiologic investigation (EpiAid) to examine the ongoing increase in unintentional fentanyl-related overdose deaths in their state. To that end, on October 26, 2015, CDC’s Epidemic Intelligence Service (EIS) Officers deployed to Columbus, Ohio, and in conjunction with ODH officials, conducted a three-week investigation which included visits to four regional hotspots of the epidemic (Hamilton, Cuyahoga, Scioto, and Montgomery Counties).

CDC Findings

The CDC discovered that the sharp increase in fentanyl-related deaths in Ohio appeared to closely coincide with a similar sharp increase in the confiscation of illicitly-produced fentanyl by law enforcement in Ohio, based on data obtained from the U.S. Drug Enforcement Administration (DEA). On March 18, 2015, the DEA issued a nationwide alert on fentanyl as threat to health and public safety.

The CDC found that the majority of the Ohio population experiencing fentanyl-related unintentional overdose deaths were male (69 percent), white (89 percent), never married (55 percent), and had some college or less education (94 percent). The average age of fentanyl decedents was 37.9 years old, with ages ranging from 17 to 71 years old. Although large metropolitan counties (population more than 1 million) had a higher number and percentage of all fentanyl-related deaths (47 percent), moderate metropolitan counties (population 250k to 1 million) had the highest rate of fentanyl-related deaths (6.63 per 100,000).

The report showed that the risk factors for fentanyl-related overdose deaths in Ohio included: male gender, white race, some college or less education, history of substance abuse problem, and current mental health problem (e.g., depression, anxiety, or bipolar disorder). Additional risk factors included a recent release from an institution within the last month (e.g. jail, hospital, and treatment facility), and a history of using high-dose opioid prescriptions.

The report also showed a correlation between heroin and fentanyl deaths in Ohio. For example, approximately 62 percent of all fentanyl and heroin decedents had a record of at least one opioid prescription from a healthcare provider during the seven years preceding their death. In addition, one in 10 heroin decedents, and one in 5 fentanyl decedents, had an opioid medication prescribed to them at the time of their death.

Further analysis of OARRS data revealed that substantial percentages of fentanyl and heroin decedents (40 percent and 33 percent, respectively) had been prescribed an opioid at high doses (at least 90 morphine milligram equivalents) at some point in the seven years preceding death. The CDC suggested further analysis to determine the duration and timing of these high dose opioid prescriptions.

CDC Recommendations

CDC’s recommendations to OPH focused on enhancing public health surveillance for fentanyl morbidity and mortality, targeting of public health response to high-burden counties and high-risk groups, enhancing and facilitating response to fentanyl-related overdoses by emergency personnel and laypersons, and improving access to naloxone and addiction services.