Fo Fore reca cast sting and and De Deflecting ecting the Opi the - PowerPoint PPT Presentation

Fo Fore reca cast sting and and De Deflecting ecting the Opi the Opioid Epidem Epidemic ic Cur Curve Donald S. Burke MD, Dean, Graduate School of Public Health, University of Pittsburgh 19 July 2017 Allegheny County Overdose Prevention Coalition Conference

Jeanine Buchanich, PhD Hawre Jalal, MD, PhD Associate Professor, Biostatistics Assistant Professor, Health Policy and Management

Outline 1. Epidemiology of overdoses 2. Reconstructing the history of the epidemic 3. Forecasting the future 4. Synoptic epidemiology 5. Economic burden in Western PA 6. Conclusions

Accidental Poisoning Age ‐ Adjusted Mortality 1981 ‐ 1983 4

Accidental Poisoning Age ‐ Adjusted Mortality 1984 ‐ 1986 5

Accidental Poisoning Age ‐ Adjusted Mortality 1987 ‐ 1989 6

Accidental Poisoning Age ‐ Adjusted Mortality 1990 ‐ 1992 7

Accidental Poisoning Age ‐ Adjusted Mortality 1993 ‐ 1995 8

Accidental Poisoning Age ‐ Adjusted Mortality 1996 ‐ 1998 9

Accidental Poisoning Age ‐ Adjusted Mortality 1999 ‐ 2001 10

Accidental Poisoning Age ‐ Adjusted Mortality 2002 ‐ 2004 11

Accidental Poisoning Age ‐ Adjusted Mortality 2005 ‐ 2007 12

Accidental Poisoning Age ‐ Adjusted Mortality 2008 ‐ 2010 13

Accidental Poisoning Age ‐ Adjusted Mortality 2011 ‐ 2013 14

Accidental Poisoning Age ‐ Adjusted Mortality Western Pennsylvania 15

Top Causes of Death by Age Group in Pennsylvania Age Group Top Cause of Death Deaths Population Rate < 1 Perinatal complications 530 142561 371.77 1 ‐ 4 Accidents due to falls, mechanical forces, drowning and suffocation 19 573343 3.31 5 ‐ 14 Motor Vehicle Accidents 21 1518107 1.38 15 ‐ 24 Motor Vehicle Accidents 285 1726198 16.51 25 ‐ 34 Overdose 567 1611833 35.18 35 ‐ 44 Overdose 502 1529401 32.82 45 ‐ 54 Ischemic Heart Disease 843 1840179 45.81 55 ‐ 64 Ischemic Heart Disease 1937 1740849 111.27 65 ‐ 74 Ischemic Heart Disease 2830 1110501 254.84 75 ‐ 84 Ischemic Heart Disease 4774 651434 732.84 85+ Ischemic Heart Disease 8037 329395 2439.93

Male Accidental Poisoning Mortality Rates 25 ‐ 34 35 ‐ 44 45 ‐ 54 55 ‐ 64 15 ‐ 24 65+ 17

Female Accidental Poisoning Mortality Rates 45 ‐ 54 25 ‐ 34 35 ‐ 44 55 ‐ 64 15 ‐ 24 65+ 18

Counties with the Top 5 Largest PA Cities Philadelphia Pittsburgh Erie Allentown Reading 19

The Epidemic of Drug Overdose Deaths Rates of drug overdose deaths by state, US 2015

APPALACHIA CLUSTER USA MEAN NEW ENGLAND CLUSTER REST OF THE USA 40 40 40 40 35 35 35 35 30 30 30 30 25 25 25 25 20 20 20 20 15 15 15 15 10 10 10 10 5 5 5 5 0 0 0 0 1970 1980 1990 2000 2010 2020 1970 1980 1990 2000 2010 2020 1970 1980 1990 2000 2010 2020 1970 1980 1990 2000 2010 2020 NH RI MA CT WV OH KY PA TN

Types of Drugs Found in the System in Fatal Overdoses Allegheny County, Pennsylvania Fentany l Heroin Number of Fatal Overdoses Cocaine Ethanol Alprazolam Overdose Free PA Karl Williams, Allegheny County Medical Examiner Jan Pringle, University of Pittsburgh, School of Pharmacy

Drugs Identified by Laboratories in Selected US Cities, 2014 National Forensic Laboratory Information System, DEA D Methamphetamine Heroin Cannabis Cocaine http://www.deadiversion.usdoj.gov/nflis/NFLIS2014AR.pdf

Heroin Use and Non-Medical Use of Pain Relievers in the Past Year among Persons Aged 12 or Older: 2002-2014 Persons Aged 12 or Older 14,000 1,400 Number of Users (Thousands) 12,000 1,200 Non ‐ medical users of pain relievers 10,000 1,000 8,000 800 6,000 600 Heroin users 4,000 400 2,000 200 0 0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Source: SAMHSA, 2014 National Survey on Drug Use and Health (September 2015). = Significant change from 2014 9/2014

Substance Dependence or Abuse for Specific Substances in the Past Year among Persons Aged 12 or Older: 2014 Numbers in thousands of users 2,400 800 NONMEDICAL USE OF PAIN RELIEVERS 1,800 600 1,200 400 HEROIN 600 200 0 0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Source: SAMHSA, 2014 National Survey on Drug Use and Health (September 2015).

SAMHSA 2014 National Survey on Drug Use and Health Current prevalence in the USA Non ‐ medical use of pain relievers 10 million Dependent 2 million Heroin users 1 million Dependent 0.6 million DSB summary

Reconstructing the History of the Opioid Epidemic

How did the Opioid Epidemic happen? 3 threads Advocacy for increased treatment of chronic pain N Engl J Med 1980 Jan10;302(2):123. Addiction rare in patients treated with narcotics. Porter J, Jick H New higher dose drug formulations aggressively marketed Cheap heroin supply introduced Xalisco, Mexico http://www.pennlive.com/opinion/2015/11/the_doctors_mistake_ ‐ _telling.html http://www.salem ‐ news.com/articles/june012011/holder ‐ purdue ‐ ms.php http://allthingswildlyconsidered.blogspot.com/2011/05/is ‐ it ‐ pill ‐ mill ‐ how ‐ do ‐ you ‐ know.html http://substencoatrib.blog.com/2013/12/14/what ‐ does ‐ black ‐ tar ‐ heroin ‐ smell ‐ like/

N Engl J Med 1980 Jan 10; 302(2): 123.

By Calendar Quarter Source: IMS Health

‐ > Q4 2010 ‐ > http://www.wsj.com/articles/SB10001424127887323798104578453210799151732

LaRochelle et al JAMA Intern Med . 2015;175(6):978-987.

Heroin OxyContin Dart et al, NEJM, 15 Jan 2015

One Book, One Communit One Book, One Community Sam Quinones discussed his book at Pitt Public Health on 10 November 20015

Forecasting the Future

Science, 4 November 2016

MOIRA DATABASE (MOrtality Information, Research, and Analysis) • A 50+ year repository of mortality and population data maintained at Pitt Public Health – CDC’s National Center for Health Statistics (NCHS) – US Census Bureau • 120 million + records of every individual death in the USA • Up ‐ to ‐ date with available geographically ‐ specific NCHS mortality data • Age, sex, race, county, ICD cause, for every death Jeanine Buchanich and Gary Marsh

OVERDOSE DEATHS / USA 50,000 45,000 40,000 35,000 deaths per year 30,000 25,000 20,000 15,000 10,000 5,000 0 1975 1980 1985 1990 1995 2000 2005 2010 2015 2020

OVERDOSE DEATHS / USA 50,000 45,000 40,000 35,000 deaths per year 30,000 25,000 20,000 15,000 10,000 5,000 0 1975 1980 1985 1990 1995 2000 2005 2010 2015 2020

USA Deaths Due to Accidental Poisoning, 1979 ‐ 2015 Re ‐ plotted on a logarithmic scale 5 4.8 Log 10 deaths / year 4.6 4.4 4.2 4 3.8 3.6 3.4 3.2 3 1975 1980 1985 1990 1995 2000 2005 2010 2015 2020 2025

USA Deaths Due to Accidental Poisoning, 1979 ‐ 2015 Data fit to log ‐ linear model 5 4.8 4.6 Log 10 deaths / year 4.4 4.2 4 3.8  Good fit for 37 years  Average increase per year = 9% 3.6  Doubling time = 8 years 3.4 3.2 3 1975 1980 1985 1990 1995 2000 2005 2010 2015 2020 2025

What are the forces and mechanisms behind this inexorable growth in overdose mortality?

Moore’s Law: The number of transistors in a dense integrated circuit doubles approximately every two years http://www.2020techblog.com/2016/03/at ‐ intel ‐ moores ‐ law ‐ unstables ‐ as ‐ intel.html

Regardless of the mechanisms involved, we can use these historical data to forecast probable future epidemic severity

USA Deaths/Year Due to Accidental Poisoning, 1979 ‐ 2015 Extrapolation to 2016 ‐ 2020 5 4.8 4.6 Log 10 deaths / year 4.4 4.2 4 3.8 3.6 3.4 3.2 3 1975 1980 1985 1990 1995 2000 2005 2010 2015 2020 2025

USA Deaths/Year Due to Accidental Poisoning, 1979 ‐ 2015 Forecast of number of deaths, 2016 ‐ 2020 5 4.8 4.6 Log 10 deaths / year 4.4 2016 50,199 4.2 2017 54,689 2018 59,579 4 2019 64,908 3.8 2020 70,713 3.6 300,089 3.4 3.2 3 1975 1980 1985 1990 1995 2000 2005 2010 2015 2020 2025

USA Deaths Due to Accidental Poisoning, 1979 ‐ 2015 Forecast of number of deaths, 2016 ‐ 2020 5 4.8 4.6 Log 10 deaths / year 4.4 Could the curve instead 4.2 begin to bend downward? 4 3.8 3.6 3.4 3.2 3 1975 1980 1985 1990 1995 2000 2005 2010 2015 2020 2025

Epidemic Pattern Pennsylvania, by year

3,500 OVERDOSE DEATHS / PENNSYLVANIA 3,000 2,500 deaths per year 2,000 1,500 1,000 500 0 1975 1980 1985 1990 1995 2000 2005 2010 2015 2020

3,500 OVERDOSE DEATHS / PENNSYLVANIA 3,000 2,500 R² = 0.967 Pennsylvania shows the same exponential deaths per year growth pattern as the entire nation 2,000 1,500 1,000 500 0 1975 1980 1985 1990 1995 2000 2005 2010 2015 2020

TX VA 4 3.5 3.5 3 3 2.5 2.5 2 2 1.5 1.5 1 1 0.5 0.5 0 0 1970 1980 1990 2000 2010 2020 2030 1970 1980 1990 2000 2010 2020 2030 PA MO 4 3.5 3.5 3 3 2.5 2.5 2 2 1.5 1.5 1 1 0.5 0.5 0 0 1970 1980 1990 2000 2010 2020 2030 1970 1980 1990 2000 2010 2020 2030 IL TN 4 4 3.5 3.5 3 3 2.5 2.5 2 2 1.5 1.5 1 1 0.5 0.5 0 0 1970 1980 1990 2000 2010 2020 2030 1970 1980 1990 2000 2010 2020 2030