TY - JOUR AU - Hannah, Haylea A. AU - Arambula, Karina AU - Ereman, Rochelle AU - Harris, Darrell AU - Torres, Alexandra AU - Willis, Matt PY - 2017/05/02 Y2 - 2024/03/28 TI - Using Local Toxicology Data for Drug Overdose Mortality Surveillance JF - Online Journal of Public Health Informatics JA - OJPHI VL - 9 IS - 1 SE - Non-Infectious Disease Surveillance Use Cases DO - 10.5210/ojphi.v9i1.7733 UR - https://ojphi.org/ojs/index.php/ojphi/article/view/7733 SP - AB - <div style="left: 93.6px; top: 369.988px; font-size: 14.7333px; font-family: sans-serif; transform: scaleX(1.08116);" data-canvas-width="66.32946666666668">Objective</div><div style="left: 109.2px; top: 385.538px; font-size: 14.7333px; font-family: serif; transform: scaleX(0.978754);" data-canvas-width="393.08385999999996">To describe the potential impact of using toxicology data to support</div><div style="left: 93.6px; top: 402.871px; font-size: 14.7333px; font-family: serif; transform: scaleX(1.00081);" data-canvas-width="220.14546666666678">drug overdose mortality surveillance.</div><div style="left: 93.6px; top: 435.855px; font-size: 14.7333px; font-family: sans-serif; transform: scaleX(1.11779);" data-canvas-width="85.93953333333334">Introduction</div><div style="left: 109.2px; top: 451.404px; font-size: 14.7333px; font-family: serif; transform: scaleX(0.969924);" data-canvas-width="392.9969333333331">Although Marin County ranks as the healthiest county in California,</div><div style="left: 93.6px; top: 468.738px; font-size: 14.7333px; font-family: serif; transform: scaleX(0.985046);" data-canvas-width="408.7940133333333">it ranks poorly in substance abuse indicators, including drug overdose</div><div style="left: 93.6px; top: 486.071px; font-size: 14.7333px; font-family: serif; transform: scaleX(1.01842);" data-canvas-width="57.71046666666667">mortality.</div><div style="left: 151.296px; top: 486.461px; font-size: 8.84px; font-family: serif;">1</div><div style="left: 155.716px; top: 486.071px; font-size: 14.7333px; font-family: serif; transform: scaleX(1.00375);" data-canvas-width="347.1291200000001">Death certificates do not always include specific detail on</div><div style="left: 93.6px; top: 503.404px; font-size: 14.7333px; font-family: serif; transform: scaleX(1.01371);" data-canvas-width="259.8635866666666">the substances involved in a drug overdose.</div><div style="left: 353.464px; top: 503.794px; font-size: 8.84px; font-family: serif;">2</div><div style="left: 357.884px; top: 503.404px; font-size: 14.7333px; font-family: serif; transform: scaleX(1.02624);" data-canvas-width="145.5727">This lack of specificity</div><div style="left: 93.6px; top: 520.738px; font-size: 14.7333px; font-family: serif; transform: scaleX(1.04015);" data-canvas-width="410.28649999999953">makes it difficult to identify public health issues related to specific</div><div style="left: 93.6px; top: 538.071px; font-size: 14.7333px; font-family: serif; transform: scaleX(1.03665);" data-canvas-width="412.8132666666668">prescription drugs in our community. We analyzed 2013 drug</div><div style="left: 93.6px; top: 555.404px; font-size: 14.7333px; font-family: serif; transform: scaleX(0.992347);" data-canvas-width="408.92956000000004">overdose death toxicology reports to determine if they could improve</div><div style="left: 93.6px; top: 572.738px; font-size: 14.7333px; font-family: serif; transform: scaleX(0.967044);" data-canvas-width="411.25153333333327">the description of drug overdose deaths in our community and to</div><div style="left: 93.6px; top: 590.071px; font-size: 14.7333px; font-family: serif; transform: scaleX(1.001);" data-canvas-width="233.19920000000013">describe associated data characteristics.</div><div style="left: 93.6px; top: 623.055px; font-size: 14.7333px; font-family: sans-serif; transform: scaleX(1.07296);" data-canvas-width="60.568733333333334">Methods</div><div style="left: 109.2px; top: 638.604px; font-size: 14.7333px; font-family: serif; transform: scaleX(1.01308);" data-canvas-width="390.0031199999999">Toxicology reports were requested from the Office of the Sheriff-</div><div style="left: 93.6px; top: 655.938px; font-size: 14.7333px; font-family: serif; transform: scaleX(0.997686);" data-canvas-width="409.18444666666664">Coroner for 37 drug overdose deaths among Marin County residents,</div><div style="left: 93.6px; top: 673.271px; font-size: 14.7333px; font-family: serif; transform: scaleX(1.01066);" data-canvas-width="412.04418666666675">comprising 95% of the 39 total drug overdose deaths in 2013.</div><div style="left: 93.6px; top: 690.604px; font-size: 14.7333px; font-family: serif; transform: scaleX(0.97933);" data-canvas-width="408.7394999999999">The remaining two deaths were excluded as they were associated with</div><div style="left: 93.6px; top: 707.938px; font-size: 14.7333px; font-family: serif; transform: scaleX(1.02963);" data-canvas-width="410.3086">inhalation of therapeutic gases. Select information from toxicology</div><div style="left: 93.6px; top: 725.271px; font-size: 14.7333px; font-family: serif; transform: scaleX(0.981137);" data-canvas-width="411.14545333333336">reports was entered into a database for aggregate analyses. Drug</div><div style="left: 93.6px; top: 742.604px; font-size: 14.7333px; font-family: serif; transform: scaleX(0.996912);" data-canvas-width="409.1490866666666">overdose deaths were considered “fully detailed” if they included the</div><div style="left: 93.6px; top: 759.938px; font-size: 14.7333px; font-family: serif; transform: scaleX(0.976471);" data-canvas-width="408.8647333333331">specific types of drugs involved in the death and did not use any broad</div><div style="left: 93.6px; top: 777.271px; font-size: 14.7333px; font-family: serif; transform: scaleX(0.974209);" data-canvas-width="408.5833266666666">language to describe the death (i.e. narcotic, multiple drugs). Student’s</div><div style="left: 93.6px; top: 794.604px; font-size: 14.7333px; font-family: serif; transform: scaleX(1.01175);" data-canvas-width="47.839133333333336">T-tests (</div><div style="left: 141.426px; top: 797.403px; font-size: 14.7333px; font-family: sans-serif;">α</div><div style="left: 150.687px; top: 794.604px; font-size: 14.7333px; font-family: serif; transform: scaleX(0.985963);" data-canvas-width="351.72592">=0.05) were used to identify significant differences between</div><div style="left: 93.6px; top: 811.938px; font-size: 14.7333px; font-family: serif; transform: scaleX(1.00096);" data-canvas-width="106.80193333333334">groups of interest.</div><div style="left: 93.6px; top: 844.922px; font-size: 14.7333px; font-family: sans-serif; transform: scaleX(1.08421);" data-canvas-width="53.21680000000001">Results</div><div style="left: 109.2px; top: 860.471px; font-size: 14.7333px; font-family: serif; transform: scaleX(1.00099);" data-canvas-width="393.7409666666667">Of the 37 drug poisoning deaths analyzed, 34 (92%) had available</div><div style="left: 93.6px; top: 877.804px; font-size: 14.7333px; font-family: serif; transform: scaleX(1.03673);" data-canvas-width="410.6327333333332">toxicology information. The remaining three (8%) deaths occurred</div><div style="left: 93.6px; top: 895.138px; font-size: 14.7333px; font-family: serif; transform: scaleX(0.999062);" data-canvas-width="411.7966666666671">outside of Marin County and were thus investigated by another</div><div style="left: 93.6px; top: 912.471px; font-size: 14.7333px; font-family: serif; transform: scaleX(1.04388);" data-canvas-width="410.59148">jurisdiction. A basic toxicology panel was ordered on 17 (50%) of</div><div style="left: 93.6px; top: 929.804px; font-size: 14.7333px; font-family: serif; transform: scaleX(0.965502);" data-canvas-width="410.9981200000002">the 34 drug overdose deaths, while an expanded toxicology panel</div><div style="left: 93.6px; top: 947.138px; font-size: 14.7333px; font-family: serif; transform: scaleX(1.04273);" data-canvas-width="410.12148666666667">was ordered on the remaining 17 (50%). Alcohol was identified in</div><div style="left: 93.6px; top: 964.471px; font-size: 14.7333px; font-family: serif; transform: scaleX(0.96321);" data-canvas-width="410.3115466666667">the toxicology screen of 15 (44%); Amphetamines were identified</div><div style="left: 93.6px; top: 981.804px; font-size: 14.7333px; font-family: serif; transform: scaleX(1.04076);" data-canvas-width="410.231986666667">in 8 (24%); and opiates were identified in 25 (74%) drug overdose</div><div style="left: 93.6px; top: 999.138px; font-size: 14.7333px; font-family: serif; transform: scaleX(0.990319);" data-canvas-width="408.91924666666677">deaths. Among the 25 deaths with at least one opiate identified on the</div><div style="left: 93.6px; top: 1016.47px; font-size: 14.7333px; font-family: serif; transform: scaleX(0.987057);" data-canvas-width="408.87209999999976">toxicology screen, the majority (52%, n=13) also had alcohol present.</div><div style="left: 93.6px; top: 1033.8px; font-size: 14.7333px; font-family: serif; transform: scaleX(1.04836);" data-canvas-width="410.65925333333337">The majority of drug overdose deaths, 18 (53%), did not have full</div><div style="left: 93.6px; top: 1051.14px; font-size: 14.7333px; font-family: serif; transform: scaleX(0.961119);" data-canvas-width="410.60621333333324">information about the type of drug involved. The average number</div><div style="left: 93.6px; top: 1068.47px; font-size: 14.7333px; font-family: serif; transform: scaleX(1.02531);" data-canvas-width="410.0213">of drugs identified on the toxicology screen of all 34 drug overdose</div><div style="left: 93.6px; top: 1085.8px; font-size: 14.7333px; font-family: serif; transform: scaleX(1.01648);" data-canvas-width="409.7413666666667">deaths was 6 (SD: 3). The average number of drugs identified in the</div><div style="left: 93.6px; top: 1103.14px; font-size: 14.7333px; font-family: serif; transform: scaleX(0.985442);" data-canvas-width="408.77780666666655">toxicology screen significantly differed (p=0.0001) between causes of</div><div style="left: 93.6px; top: 1120.47px; font-size: 14.7333px; font-family: serif; transform: scaleX(1.01564);" data-canvas-width="409.7767266666668">death that were fully detailed (Mean: 4; 95% CI: 3-5) and those that</div><div style="left: 93.6px; top: 1137.8px; font-size: 14.7333px; font-family: serif; transform: scaleX(1.00091);" data-canvas-width="286.84326666666664">were not fully detailed (Mean: 8; 95% CI: 7-10).</div><div style="left: 93.6px; top: 1170.79px; font-size: 14.7333px; font-family: sans-serif; transform: scaleX(1.10289);" data-canvas-width="88.41473333333334">Conclusions</div><div style="left: 109.2px; top: 1186.34px; font-size: 14.7333px; font-family: serif; transform: scaleX(0.999803);" data-canvas-width="395.9052933333334">Data from the Sheriff-Coroner’s office provided detail on the</div><div style="left: 93.6px; top: 1203.67px; font-size: 14.7333px; font-family: serif; transform: scaleX(1.04444);" data-canvas-width="410.187786666667">types of drugs involved in overdose deaths; however, it is difficult</div><div style="left: 93.6px; top: 1221px; font-size: 14.7333px; font-family: serif; transform: scaleX(0.992499);" data-canvas-width="408.95902666666655">for local public health practitioners to make decisions about causality</div><div style="left: 93.6px; top: 1238.34px; font-size: 14.7333px; font-family: serif; transform: scaleX(0.98607);" data-canvas-width="411.60218666666685">or contributions of these drugs to the death. These data may be</div><div style="left: 93.6px; top: 1255.67px; font-size: 14.7333px; font-family: serif; transform: scaleX(0.980404);" data-canvas-width="410.9362399999999">useful in understanding the difference between fully detailed and</div><div style="left: 530.4px; top: 368.204px; font-size: 14.7333px; font-family: serif; transform: scaleX(0.969283);" data-canvas-width="410.95981333333344">non-detailed drug overdose deaths, and a broader context of drug</div><div style="left: 530.4px; top: 385.538px; font-size: 14.7333px; font-family: serif; transform: scaleX(0.986095);" data-canvas-width="408.75275999999997">combinations associated with these deaths. Less drugs were identified</div><div style="left: 530.4px; top: 402.871px; font-size: 14.7333px; font-family: serif; transform: scaleX(0.99265);" data-canvas-width="409.0047000000001">in the toxicology screen of deaths that were fully detailed, suggesting</div><div style="left: 530.4px; top: 420.204px; font-size: 14.7333px; font-family: serif; transform: scaleX(1.03373);" data-canvas-width="410.32333333333327">that overdose deaths that are not fully detailed may be exceedingly</div><div style="left: 530.4px; top: 437.538px; font-size: 14.7333px; font-family: serif; transform: scaleX(1.03132);" data-canvas-width="410.1907333333336">complex, making it difficult for medical examiners and coroners to</div><div style="left: 530.4px; top: 454.871px; font-size: 14.7333px; font-family: serif; transform: scaleX(0.989577);" data-canvas-width="408.87651999999997">assess causality. Approximately three-quarters of 2013 drug overdose</div><div style="left: 530.4px; top: 472.204px; font-size: 14.7333px; font-family: serif; transform: scaleX(0.977647);" data-canvas-width="411.2633199999999">deaths contained opiates on the toxicology screen, indicating that</div><div style="left: 530.4px; top: 489.538px; font-size: 14.7333px; font-family: serif; transform: scaleX(0.957985);" data-canvas-width="410.54433333333367">opiates may be a significant contributor to overdose deaths in our</div><div style="left: 530.4px; top: 506.871px; font-size: 14.7333px; font-family: serif; transform: scaleX(0.98675);" data-canvas-width="411.31046666666685">community. Our results are descriptive in nature; therefore, even</div><div style="left: 530.4px; top: 524.204px; font-size: 14.7333px; font-family: serif; transform: scaleX(1.03604);" data-canvas-width="410.4117333333336">though alcohol or opiates were identified on the toxicology screen,</div><div style="left: 530.4px; top: 541.538px; font-size: 14.7333px; font-family: serif; transform: scaleX(1.01784);" data-canvas-width="409.88428000000005">they may not be responsible for the overdose death. Given that over</div><div style="left: 530.4px; top: 558.871px; font-size: 14.7333px; font-family: serif; transform: scaleX(1.04083);" data-canvas-width="410.2791333333335">half of our 2013 overdose deaths were not fully detailed with drug</div><div style="left: 530.4px; top: 576.204px; font-size: 14.7333px; font-family: serif; transform: scaleX(1.00687);" data-canvas-width="409.5277333333331">type, local jurisdictions should work closely with their corner and/or</div><div style="left: 530.4px; top: 593.538px; font-size: 14.7333px; font-family: serif; transform: scaleX(0.982289);" data-canvas-width="408.7630733333334">medical examiner to fully detail death certificates with drugs involved</div><div style="left: 530.4px; top: 610.871px; font-size: 14.7333px; font-family: serif; transform: scaleX(1.00083);" data-canvas-width="113.34353333333334">in overdose deaths.</div> ER -