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MontgomeryCountyResidentsHospitalEmergencyDepartmentVisitsforAccidentalOverdoseonSelectedDrugs,20072010RusselFalck,MA,RobertCarlson,PhD,RamintaDaniulaityte,PhD,TimLane,MEdCenterforInterventions,Treatment&AddictionsResearchDepartmentofCommunityHealthBoonshoftSchoolofMedicineWrightStateUniversityDayton,OHSeptember2011Funded,inpart,byacontract(PreventingUnintentionalPrescriptionDrugPoisoning)fromPublicHealthDayton&MontgomeryCounty.1IntroductionThisbriefreportdescribes,inverygeneralterms,MontgomeryCountyresidentswhopresentedtoEmergencyDepartments(EDs)athospitalsinMontgomeryCountyfortreatmentofanaccidentaldrugoverdose(OD)from20072010.ItspurposeistobroadentheperspectiveontheunintentionaldrugoverdoseproblemasmanifestedinMontgomeryCounty,Ohio.Todate,theissuehasbeenframedlargelybymortalitydatafromtheMontgomeryCountyCoronersOfficeandtheOhioDepartmentofHealth.Whilehighlyinformativeandextremelyuseful,thesedataonlypartiallyreflectthenatureandextentoftheproblemastheyarebasedsolelyonpeoplewhohavediedfromanaccidentaldrugoverdose.ItisourhopethatbringinglocalEDODdatatolightwillhelpinformthediscussionandleadtoanappropriateresponsetoapublichealthproblemthatisaffectingourcommunityandmanyothers.MethodsTabulationsinthisreportarebasedondataprovidedinadeidentifiedformbytheGreaterDaytonAreaHospitalAssociation.ThedatawereusedtogainabetterunderstandingaccidentalODphenomenoninMontgomeryCountyaswellastodevelopaveryroughprofileofresidentswhopresentedtoEDsinMontgomeryCountyfortreatmentofaccidentaldrugoverdoses.Thevariablesconsideredwereage,gender,race/ethnicity,residency,andICD9codesforselecteddrugs.Residencywasdeterminedbythezipcodeinformationcollectedbythehospitals.ICD9codesidentifiedaccidental(asopposedtointentional)overdosesassociatedwithspecificdrugsordrugtypes.InternationalClassificationofDiseasesNinthRevision(ICD9)codesareusedbyhospitalstospecifydiagnosesonbillablereimbursementclaims.ICD9codeswereusedtoenumerateEDODsassociatedwiththefollowing7drugs/drugtypes:amphetamines,benzodiazepines,cocaine,hallucinogens,heroin,methadone,andprescription(Rx)opioidsotherthanmethadone.Univariatestatisticswereusedtodescribethedatawhereapplicable.FindingsBetweenJanuary1,2007andDecember31,2010,EDsinMontgomeryCountytreated1937MontgomeryCountyresidentswhoreceivedICD9codesindicatingaccidentaldrugpoisonings.Ofthese,1622(83.7%)visits(373in2007;447in2008;415in2009;387in2010)involvedoneormoreoftheaforementioned7drugs(seeGraphsonpages23).Ofthe315casesnotincludedinthisreport,265(84.1%)involvedeitherantidepressantsorantipsychotics.Theremainderinvolvedbarbiturates,alcohol,orotherdrugswhoseidentitycouldnotbedeterminedwithcertaintyfromtheICD9coding.24.0%4.3%4.4%4.6%4.9%5.0%5.0%5.3%5.9%6.2%7.3%0.0% 1.0% 2.0% 3.0% 4.0% 5.0% 6.0% 7.0% 8.0% 9.0% 10.0%45449(WestCarrollton)45414(HarrisonTownship)45404(NorthDayton)45402(LowerDaytonView,Downtown)45420(Belmont)45405(NorthwestDayton)45342(Miamisburg)45406(UpperDaytonView)45410(EastDayton)45424(HuberHeights)45403(EastDayton)ZipCodesZipCodesContributing4%ofTotalODsatEDs(20072010)2.3%21.5%76.2%47.9%52.1%1.3%13.8%20.7%19.2%24.3%20.8%2.7%(n=43)4.5%(n=73)17.2%(n=279)20.2%(n=327)7.2%(n=117)31.9%(n=517)40.5%(n=657)0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0%OtherAfricanAmericanWhiteMaleFemale3Discussion2007 2008 2009 2010Cocaine 86 76 57 60Heroin 71 99 90 67Methadone 31 27 29 30RXOpioids 108 140 139 130Benzodiazepines 136 173 178 170EDVisits 373 447 415 387050100150200250300350400450500EDVisitsandMentionsofSelectedDrugsbyYear,200720102.2%12.3%85.5%47.9%52.1%0.9%12.1%22.5%22.1%22.1%20.4%4.3%4.3%6.1%7.4%7.4%7.8%11.7%0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0%OtherAfricanAmericanWhiteMaleFemale4DiscussionThedatauponwhichthisreportisbasedaresubjecttoanumberoflimitations.First,thedataarefromhospitalbillingdepartments,notmedicalrecordreviews.Sometimestherearedifferencesbetweenpatientmedicalrecordsandhowdiagnosesarecodedandsubsequentlybilled.Second,notallaccidentaldrugoverdosesarediagnosedassuch.Thus,thedatainthisreportlikelysomewhatunderestimatetheextentoftheproblem.Third,foravarietyofreasons,theidentityofthedrug(s)onwhichapersonhasoverdosedisnotalwaysverifiedbytoxicologytestsatahospitalduringanEDvisit.Simply,sometimesthereisnoquicktestforthedrugwhichhascausedtheproblem.Forexample,asofthiswriting,methcathinone,MDPVandmephedrone,possibleingredientsinsomebathsalts,arenotdetectablewithaninstanturineorsalivatest.Further,thereis,asofthiswriting,somevariationintheICD9codingofbathsaltoverdoses.SometimestheyarecodedunderHallucinogens,sometimesunderStimulants,andsometimesunderUnspecifiedagents.Consequently,thereissomereasontobelievethatnoteveryaccidentaldrugoverdosecaseiscodedappropriatelywithrespecttothepoisoningagent.Fourth,apersonwhohasoverdosedontwo(ormore)drugsthatfallunderthesameICD9code,e.g.,hydrocodoneandoxycodone(ICD9codeE850.2),arecodedonlyonce.Thus,thenumberofmentionsforaspecificdrug(ordrugtypeordrugclass)citedinthisreportarelikelylowerthantheiractualoccurrencesinceasinglecodemaynotreflectthecompletepoisoningpicture.Fifth,zipcodesareimperfectindicatorsoftheextentandlocation(s)oftheproblemwithinthecounty.Thishasanumberofimplications.Forexample,onlypeoplewhoreportedanaddresswithaMontgomeryCountyzipcodeareincludedinthedataset.Thus,nonresidentswhooverdosedinMontgomeryCountyandvisitedahospitalinMontgomeryCountyarenotincludedinthedata.Similarly,MontgomeryCountryresidentswhooverdosedandpresentedatahospitaloutsideofMontgomeryCountyarenotincludedinthedataeither.Inaddition,althoughthevastmajorityofzipcodesinthisreportarecontainedwithintheboundariesofMontgomeryCounty,severalbleedintocontiguouscounties.Sixth,thedatapresentedrepresentvisits/cases,notseparateindividuals.Sincethedataweredeidentified,itisnotpossibletoascertainthenumberofpeoplewhocontributedmorethanonecasetothedatabase.Seventh,althoughthedatashowhowmanycasesweretreatedatEDsinMontgomeryCountyfrom20072010,theydonotreflecttheextentoftheoverdoseproblem,notonlyforsomeofthereasonsnotedabove,butalsobecausethereisevidencetoindicatethevastmajorityofpersonswhodiefromaccidentaldrugoverdosesdiebeforereachinganED.Forexample,in2010,only20ofthe127(15.7%)peoplewhodiedinMontgomeryCountyfromanunintentionaldrugoverdosereachedahospitalED.Thus,whenfactoringindatafromtheMontgomeryCountyCoronersOffice,thereisgoodreasontothinkthereare,onaverage,500pluscasesofaccidentaldrugoverdosetheinthecountyeachyearinvolvingtheselecteddrugshighlightedinthisreport.Inaddition,foravarietyofreasons,anunknownnumberofdrugoverdosesnevercometotheattentionofmedicalcentersorlegalauthorities.SomeODsare5treatedbybystanders,friendsandfamilyatthesceneoftheeventforfearoflegalrepercussions.Evenwiththeselimitations,thedataprovideimportantperspectiveontheaccidentaldrugoverdoseprobleminMontgomeryCounty.Perhapsthemostinterestingandpotentiallyusefulfindingemanatesfromthezipcodedata.AlthoughODEDcasesoccuracrossthecounty(indeed,theMiamiValley,OhioandtheUS)andinallzipcodes,morethanonehalf(52.5%)ofthecasesoccurredamongpeoplewhoseresidencewasinoneofelevenzipcodes(seeMapsonpages810).Thereare39zipcodesinMontgomeryCounty.Itisimportanttonotethatpopulationdensityvariesacrosszipcodesasdoahostofeconomicanddemographicfactors.Nevertheless,whilethesefindingsmaysurprisesomeobserversandnotothers,theycanhelpgeographicallytargetneighborhoodlevelinterventionstohelpreducetheaccidentalODproblem.Suchinterventionscouldbeimplementedfollowingwellknownhealthbehaviortheoryandpublichealthpractices.Whileinterventionstargetingusersandtheirfamiliesmayhelpreducetheproblem,theywillnotsolveitastheproblemismultifactorialinnature(Websteretal.2011),andpublichealthorientedinterventionswillnotimpactallfactors. DrugmentionsfromEDODsareveryconsistentwithMontgomeryCountyCoronersOfficetoxicologyreportsinthatdatafrombothsourcesshowsedatives/tranquilizersandRxopioidsarethemostfrequentlymentioneddrugsrelativetootherdrugsinaccidentalODcases.ThemostfrequentlymentioneddrugsintheCoronersOffice2010autopsyreportsweresedatives,93%ofwhichwerebenzodiazepines,followedRxopioids(WSUCITAR2011);themostfrequentlymentioneddrugsinEDODcases,regardlessofthesamplesize(1937or1622),werebenzodiazepines,suchasalprazolam,followedbyRxopioids,suchashydrocodoneandoxycodone.TherelativelylargenumberofpeoplesufferinganODcausedorcomplicatedbybenzodiazepinesdemonstratesnotonlythattheyarewidelyprescribedandmisusedbutthattheirusecanresultinsymptomswhichmayprecipitateanEDvisit.Fortunately,mostbenzodiazepineshaverelativelyhighmarginsofsafetywhennotcombinedwithotherdrugsthatdepressthecentralnervoussystem(CNS).WhencombinedwithotherCNSdepressants,suchasanopioidoralcohol,benzodiazepineusecanbeveryproblematic,sometimeslethal.SpecificdrugmentiondataforthefouryeartimeperiodcoveredbythisreportshowalargeincreaseinbenzodiazepineandRxopioids(exclusiveofmethadone)mentionsfrom2007to2008,thenstabilization.Methadonementions(virtuallyallofwhicharerelatedtomethadoneprescribedforpainrelief,notmethadoneusedtotreatdrugaddiction)haveremainedstableoverthereportingperiod.Cocainementionsappeartohavedecreasedsomewhat,whileheroinmentionsrevealnopattern.Notably,anygivencasecancontributemorethanonedrugtothedrugmentioncount.Infact,datashowthat,ataminimum,giventheaforementionedlimitationinICD9coding,about14%oftheEDODcasesinvolvedpeoplewhohadmorethanoneopioid(heroin,methadone,otherRxopioids)intheirsystem,oranopioidanda6benzodiazepine,uponarrivalatthehospital.Generally,accidentalODsinvolvingmultipleCNSdepressantshavethehighestlikelihoodofverybadoutcomes.RecentlypublisheddatafromtheCDCshowthemostwidelyprescribeddrugsintheUnitedStatesforpeopleaged2059wereantidepressantsfollowedverycloselybyanalgesics.CDCdataalsoshowthatproportionatelymorewomenthanmenareprescribedthesedrugs,asarewhitescomparedtootherracial/ethnicgroups(Guetal.2010).Thus,itisnotsurprisingthatwomenandwhitesmadeupalargerproportionoftheEDODpopulationinMontgomeryCountythandidothergroups.Notably,ageandrace/ethnicitydataforMontgomeryCountyEDODsareverymuchinconcertwith2010USCensusdataforthecounty.Intermsofgender,censusdatashowabout52%ofMontgomeryCountyresidentsarewomen;racially/ethnically,about74%ofthecountyresidentswhiteand21%areAfricanAmerican.AlthoughthisreportfocusesonthegeneraldemographicsofpeoplewhooverdosedandthespecifictypesofdrugsthatbroughtthemtoanED,thecostofODEDvisitsmeritssomemention.Wecomputedtheaveragebilledcostofoutpatienttreatment(anEDODvisitwherethepatientwasnotadmittedtothehospitalasaninpatient,akatreatandrelease)foranopioid(includingheroin)overdosein2010.Theaveragecost,basedon54visitswheretheprimaryICD9codewasanopioidpoisoning,was$4588percase.Thissuggeststhatthecostoftreatingthe227opioidcasespresentingatareahospitalEDsin2010was,ataminimum,$1,041,476.Notably,thesecostsdonotfactorinthoseassociatedwiththeservicesprovidedbypublicallyfundedEmergencyMedicalServices.Additionally,ifopioidODcasesresultingininpatienttreatmenthadbeenconsidered,themonetarycostswouldbesubstantiallymore,asthecostforthesecasesismuchhigherthanfortreatandreleasecases.Further,theODtreatmentcostforotherdrugs,suchasbenzodiazepines,wasnotcalculated.Thecriticallyimportantpointhereisthat,asidefromtheincalculablehumancostsassociatedwithdrugoverdoses,thereisasubstantialfinancialcostaswell.ConclusionThisisabriefreportwithanumberoflimitations.Still,itprovidesinformationthatallowsadditionalinsightintotheaccidentaldrugoverdoseprobleminourcommunity.Thenatureandextentofthephenomenonareclearer.Asidefromthe500plusMontgomeryCountyresidentswhoexperiencedanODin2010,theirfamily,friends,andcoworkerswerealsoaffectedbytheeventinsomeway.So,inarealsense,theseunintentionalODslikelytouchedthousandsofpeople.WealsonowhaveabetterideaoftheshorttermhealthcarecostsassociatedwithasegmentoftheODproblem.Virtuallyallofuspayfortheproblem,andthecosts,whetherhumanandfinancial,arenotinsignificant.Wealsoknowthatalthoughtheproblemexistsacrossthecounty,itismoreprevalentinsomeareasthaninothers.Thisfindingcouldbeusefulinthedevelopmentandimplementationofvariousinterventionstoreducetheproblem.7AcknowledgmentsTheassistanceoffollowingindividualsandorganizationsinhelpingmakethisreportpossibleisgratefullyacknowledged:LinnaLi,WSUCITAR,datamanagement;CarolHooker,WSUCUPA,mapping;KymSellers,WSUCITAR,editorialsupport;andtheGreaterDaytonAreaHospitalAssociationandareahospitalsforthedata.Thisreportwasfunded,inpart,underacontractfromPublicHealthDayton&MontgomeryCounty.ReferencesGu,Q,DillionCF,BurtVL.2010.Prescriptiondrugusecontinuestoincrease:USprescriptiondrugdatafor20072008.NationalCenterforHealthStatisticsDataBrief(Number42),CentersforDiseaseControlandPrevention.(www.cdc.gov/nchs/data/databriefs/db42.pdf).WebsterLR,CochellaS,DasguptaNetal.2011.AnanalysisoftherootcausesforopioidrelatedoverdosedeathsintheUnitedStates.PainMedicine,12(s2635).WrightStateUniversityCenterforInterventions,TreatmentandAddictionsResearch(CITAR).2011.UnintentionalRxDrugPoisoningProject,PoisonDeathReviewSummaryReport,2010.(www.med.wright.edu/citar/prescriptiondrugs)8OverdoseCasesResultinginDeath,20072010MontgomeryCounty,Ohio9OverdoseCasesResultinginEDVisits,20072010MontgomeryCounty,Ohio10OverdoseCases,20072010(EDODsandDeathsCombined)MontgomeryCounty,Ohio

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