Drilling Down into the Opioid Crisis...
The Varied Nature of Opioid Deaths in Central Florida
Seems like the opioid crisis is in the news every day. But are we seeing the whole story? We hear that death rates are up. Is the problem the same, or are we dealing with multiple challenges and opportunities? It is useful to look at the varied nature of opioid deaths in Central Florida. [i]
By understanding one area of the U.S., perhaps we can begin to understand that it is not the same issues throughout the country. Like other aspects of healthcare, we need to think globally, but act locally…
Why We Care…
“In 2015, opioids were responsible for more than 33,000 deaths nationwide; and nearly 3,900 deaths in Florida”.[ii] Thus began Governor Scott’s press release in May 2017. In the past 6 years, more than 183,000 Americans died from overdoses related to prescription opioids.[iii]
“Every day, more than 1,000 people are treated in emergency departments for misusing prescription opioids,”[iv] and “more than 40 people die from prescription opioid overdose.”[v] Counting heroin and other non-prescription sources, an average of 91 Americans die every day from opioid overdose. This amounted to 42,000 deaths in 2016 alone. 40% were prescription opioids. (CDC.gov)[vi]
Deaths involving opioids account for more than one-half million Americans in the past 15 years alone. And the rate of death form prescription opioids, like oxycodone, hydrocodone and methadone, has quadrupled since 1999.[vii]
We continue to promote the need for a national prescription database described in our free e-Book, Med Wreck: Proposing a Solution for the Nightmare of Medication Reconciliation.
Where Do We Find This Data?
Florida Law Enforcement publishes a semi-annual report[viii] on drugs identified by their Medical Examiners in deceased persons. The data is reported by districts (see Figure 1 map), with Pasco and Pinellas Counties combined as District 6. Hillsborough County (including Tampa) to the south comprises District 13. To the north, District 5 includes Hernando, Citrus, Lake, Marion and Sumter Counties. To the east are District 10 (Polk, Hardee and Highlands Counties, including Lakeland) and District 9 (Orange and Osceola Counties, including Orlando). The report highlights are in the sidebar article.
As summarized in the report, most Florida drug-related deaths involve morphine, heroin, fentanyl and oxycodone. Note that morphine (often obtained by diversion of the drug at the point of care[ix]) and oxycodone (a prescription pill) are the most common agents present in these deaths.
On table above: Cause of Death means coroner ruled the drug was the cause of death. Present at Death means that toxicology detected the drug in the deceased’s blood stream, but the drug was not attributed as the cause of death by the coroner.
Looking at year-to-year comparisons, we see an increase in both heroin and fentanyl across the State. While heroin is purely an illicit drug not available legally in the U.S., fentanyl, a typical diversion drug like morphine, can now be synthesized[x]. In addition, fentanyl is the most potent of the agents and may be a factor in very small doses that may get missed during typical drug screening. This makes it difficult to detect as well as very lethal.
*Note: Many of the deaths above had several drugs contributing to the death. Thus the count of specific drugs listed is greater than the number of cases.
The stats from Pasco and Pinellas Counties paint a unique picture of the problem…
Elderly Deaths from Prescription Pain-killers Plague Pasco and Pinellas Counties
In Medical Examiner District 6, opioid deaths are quite different from other regions of the State. These counties lead the State in the number of prescription opioid deaths and in the demographics of those deaths. Typically, the victims of accidental opioid death in this area are adults older than 50, and with two common prescription pain killers: oxycodone and hydrocodone, representing 10-11% of these deaths statewide. District 6 also leads the State in methadone overdoses, though the most common victim is middle-aged. The counties’ victims of morphine and fentanyl are also more likely to be elderly. Heroin deaths are rare in these two counties.
District 6 (which includes Pasco County) stands out in its uniqueness in prescription opioids and victims over 50. The Orlando area leads the State otherwise in morphine, fentanyl and heroin deaths. It is interesting that Tampa and Hillsborough County has lower opioid deaths than Pasco-Pinellas in all categories.
The U.S. Centers for Disease Control (CDC) has launched its Rx Awareness campaign to focus on adults ages 25-54 who have taken opioids at least once for medical or non-medical use. The data above, however, suggests that this may not be optimal for counties like Pasco and Pinellas (Florida) that represent more elderly in their victims of opioid deaths.
Implications for Opioid Deaths in Central Florida and Beyond...
Central Florida represents two major metropolitan areas (Tampa and Orlando). It is important for policy makers to better understand that the opioid crisis has different implications for communities. It is not just an issue of "street drugs" or "prescription abuse". As demonstrated with the data on opioid deaths in Central Florida, the problem requires understanding of local factors and directed solutions. As always, healthcare should see where the data leads, think globally, and act locally.
Note: Please visit Opioid FAQs to see the most frequently asked questions about this topic.
References and Footnotes:
[i] Smith, PA. “Special Briefing on Opioid Abuse in Tampa Bay” Compiled for Pasco County (FL) Commissioners. Jan 2018.
[ii] Governor Scott Directs DCF to Immediately Draw Down $27 Million Federal Grant to Fight Opioid Epidemic. Press Release, May 3, 2017. http://www.myflfamilies.com/press-release/governor-scott-directs-dcf-immediately-draw-down-27-million-federal-grant-fight-opioid
[iii] Centers for Disease Control and Prevention. Wide-ranging Online Data for Epidemiologic Research (WONDER). Atlanta, GA: National Center for Health Statistics; 2016. http://wonder.cdc.gov. Accessed December 2016.
[iv] Substance Abuse and Mental Health Services Administration. Highlights of the 2011 Drug Abuse Warning Network (DAWN) findings on drug-related emergency department visits. The DAWN Report. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration; 2013. http://www.samhsa.gov/data/2k13/DAWN127/sr127-DAWN-highlights.htm
[v] U.S. Department of Health and Human Services, Office of the Surgeon General. Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, DC: U.S. Department of Health and Human Services; November 2016.
[vii] See Med Wreck: The Rising Opioid Epidemic. October 4, 2017. https://healthitaccelerator.com/med-wreck-the-rising-opioid-epidemic/
[viii] 2015 Medical Examiners Commission Interim Drug Report. Florida Department of Law Enforcement, April 2016. http://www.floridahealth.gov/statistics-and-data/e-forcse/news-reports/_documents/2015med-exam-interim.pdf
[ix] Diversion occurs when medical practitioners or nurses who have access to narcotics divert doses intended for legitimate patient use for personal use or sale.
[x] While morphine and fentanyl are common drugs for diversion, synthetic fentanyl has now become more prevalent. A typical dose of morphine 10 milligrams (mg) translates to fentanyl doses of 50-100 micrograms (mcg). Fentanyl is 81 times more potent than morphine, thus little room for error between effect and overdose.
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Drugs Identified in Deceased Persons by Florida Medical Examiners: Report Summary[i]
"Some general statewide trends for the first half of 2015 (January – June) are listed below. Please note: comparisons to 2014 are based on data for January through June.
- Total drug-related deaths increased by 13.9 percent (570 more) when compared with the first half of 2014.
- 2,548 individuals (261 more deaths than the first half of 2014) died with one or more prescription drugs in their system. The drugs were identified as both the cause of death and present in the decedent. These drugs may have also been mixed with illicit drugs and/or alcohol.
- 1,155 individuals (179 more deaths than the first half of 2014) died with at least one prescription drug in their system that was identified as the cause of death. These drugs may have been mixed with other prescription drugs, illicit drugs, and/or alcohol.
- Prescription drugs (benzodiazepines, carisoprodol/meprobamate, zolpidem, and all opioids, excluding heroin) continued to be found more often than illicit drugs, both as the cause of death and present at death. Prescription drugs account for 68.9 percent of all drug occurrences in this report when ethyl alcohol is excluded.
- Heroin (93.3 percent), fentanyl (72.8 percent), methadone (66.1 percent), morphine (57.8 percent), cocaine (52.5 percent), and oxycodone (52.2 percent) were listed as causing death in more than 50 percent of the deaths in which these drugs were found.
- The five most frequently occurring drugs found in individuals were ethyl alcohol (2,288), benzodiazepines (2,182, including 666 alprazolam deaths), cocaine (840), cannabinoids (785), and morphine (670). The increase in positive cannabinoid findings is due to the increased surveillance by medical examiner offices and not a direct reflection of the increased use of cannabis by decedents.
- The drugs that caused the most deaths were benzodiazepines (558, including 281 alprazolam deaths), cocaine (441), morphine (387), ethyl alcohol (384), heroin (320), fentanyl (289), and oxycodone (274).
- Occurrences of heroin increased by 107.9 percent (178 more) and deaths caused by heroin increased by 114.8 percent (171 more) compared with the first half of 2014; 94 percent of all heroin occurrences were in accidental deaths.
- Occurrences of fentanyl increased by 97.5 percent (196 more) and deaths caused by fentanyl increased by 105.0 percent (148 more) compared with the first half of 2014.
- Occurrences of methadone decreased by 4.8 percent (12 less) and hydrocodone remained the same compared with the first half of 2014. Deaths caused by methadone decreased by 8.7 percent (15 less) and hydrocodone decreased by 12.9 percent (16 less) during the same period.
- Occurrences of oxycodone increased by 8.2 percent (40 more) and deaths caused by oxycodone increased by 21.2 percent (48 more) compared with the first half of 2014.
- Occurrences of cocaine increased by 12.1 percent (91 more) and deaths caused by cocaine increased by 23.5 percent (84 more) compared with the first half of 2014.
- Alprazolam (Xanax) and nordiazepam dominate the category of benzodiazepines. Occurrences of alprazolam increased by 11.7 percent (70 more) and nordiazepam increased by 3.9 percent (12 more) compared to the first half of 2014. Alprazolam and nordiazepam are rarely the sole cause of death, but are common as contributing to the cause of multi-drug deaths. Note that since the drugs diazepam (Valium) and chlordiazepoxide (Librium) are normally broken down in the body into the drug nordiazepam, many occurrences of nordiazepam may represent ingestion of these other benzodiazepines.
- Occurrences of methamphetamine increased by 16.1 percent (18 more) and amphetamine increased by 34.6 percent (46 more) compared with the first half of 2014.
- Reporting of occurrences of illicit fentanyl analogs was not specifically requested by the Commission in 2015. Due to the rapid rise of deaths associated with fentanyl analogs, many districts voluntarily reported data; however, the data is not complete. A total of 49 occurrences of fentanyl analogs were reported for the period of January through June 2015, with the majority identified as acetyl fentanyl (53 percent). Refer to page 24 of the report for a representation of the frequency of occurrence of fentanyl analogs. Reporting of fentanyl analogs by all districts will begin with the 2016 Drugs Identified in Deceased Persons Reports."
[i] 2015 Medical Examiners Commission Interim Drug Report. Florida Department of Law Enforcement, April 2016. http://www.floridahealth.gov/statistics-and-data/e-forcse/news-reports/_documents/2015med-exam-interim.pdf