Highlight on Massachusetts: Seeing the opioid crisis differently

Massachusetts, like many states, has an opioid epidemic. The number of individuals experiencing opioid-related overdose and death in Massachusetts was four-times higher in 2015 than it was in 2000. The crisis isn’t new, but state health officials have taken a new step to raise awareness and disseminate information concerning the epidemic. State health officials released an interactive website designed to display information graphically so that it will have a more profound impact.

Chapter 55

As part of an effort to combat the epidemic, Chapter 55 of the Acts of 2015 was signed into law—a piece of state legislation that permitted an analysis of government datasets to achieve better understanding of the opioid crisis. The Massachusetts Department of Public Health (DPH) led the data analysis, which culminated in a report: The Chapter 55 Report. The report identified a number of trends as well as analyzed key factors impacting the crisis, including: costs, growth of addiction, prescriptions, illegal drugs, and demographics.

Crisis

The crisis in Massachusetts is above the national average, due in part to a sharp rise in opioid-related deaths in the last two years. For example, 2014 was the first year since 1999 that the fatal overdose rate in Massachusetts was more than double the national average. Additionally, while, in 2000, about one third of admissions to substance abuse treatment centers were opioid-related, by 2015, opioid-related issues accounted for more than half of admissions. A similar pattern was documented by the Health Policy Commission in terms of emergency department visits and hospitalizations.

Deaths

The website offers novel displays of opioid-related death data, including state maps that demonstrate by county across three blocks of time—2001 to 2005, 2006 to 2010, and 2011 to 2015—the number of individuals, per 100,000 people, who died as the result of opioids. By scrolling over a county, the maps demonstrate the five-year death rate for that county and the death rate per 100,000 people. Some counties have undergone massive increases in their opioid-related death rate. For example, from 2001 to 2005, Eastham County had a five-year death count of zero and a death rate per 100,000 people of zero. In stark contrast, from 2011 to 2015, Eastham County had a five-year death count of nine and a death rate per 100,000 people of 36.3.

Heroin

Another set of maps demonstrates the percentage of patients in treatment who listed heroin as their primary substance of abuse. The four separate maps correspond to the frequency of that designation, by county, in 2000, 2005, 2010, and 2015. In 2000, only about 20 counties were identified as having over 46 percent  of substance abuse treatment patients indicating heroin as their primary substance of abuse—a designation shown as green on the map. The 2000 map is merely speckled with green. By 2015, however, the map is almost entirely green, with the majority of counties marked as having over 46 percent of patients indicating heroin as their primary substance of abuse.

Transition

The website also uses graphics to display the trends related to the transition between prescriptions and illegal opioids.  The graphics demonstrate, based upon specific drugs—heroin, fentanyl, prescription opioids, methadone—the likelihood that an individual had a legal opioid one, three, or six months before death.  For example, in Massachusetts, between 2013 and 2014, 867 individuals who died of an opioid-related overdose had a positive toxicology screen for heroin. Sixty-five percent of those individuals had a legal opioid prescription between 2011 and 2014.

Conclusion

The website offers information about addressing substance abuse and gives examples of steps that can still be taken to expand treatment options, tailor treatment and prevention efforts, and develop post-incarceration treatment plans. The Massachusetts DPH aims to continue to use data as a tool to obtain insight and solutions for the problem.  If nothing else, the agency’s graphic depiction of the Chapter 55 Report is successful in that it is a stark and dramatic way to say: something is wrong.

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.