Accuracy of Medical Examiner's Assessment for Near-Real-Time Surveillance of Fatal Drug Overdoses, King County, Washington, March 2017-February 2018

Evaluation of a Suspected Overdose Form for Timely Surveillance of Fatal Drug Overdoses, Multnomah County, OR, 2020-2021

OBJECTIVES

There is a significant delay in finalization of drug overdose deaths, and a need to more quickly identify suspected overdoses to improve public health response. The objective of our study was to describe creation of a suspect overdose form and evaluate its use.

DESIGN

Evaluation of a suspected overdose form used to record information related to death investigation with matching to state vital records. We calculated the toxicology turnaround time for matched records, and also calculated sensitivity, specificity, positive predictive value, and negative predictive value of the form compared to vital records as the gold standard.

SETTING

Multnomah County, Oregon, deaths investigated by the County Medical Examiner between January 2020 and December 2021.

MAIN OUTCOME MEASURE

Sensitivity of the suspected overdose form.

RESULTS

We analyzed 2818 matched death records in total during the study period. The average turnaround time for the 1673 records with toxicology results was 101 days. In 2020, sensitivity of the form was 74%, but this increased to nearly 95% in 2021.

CONCLUSIONS

Multnomah County's suspected evaluation form provides a timelier indicator of deaths suspected to be from drug overdose, has good sensitivity to detect true overdoses, and can help guide more rapid public health and public safety response activities.

Evaluation of in-house drug evidence testing by King County Medical Examiner's Office in "real-time" fatal overdose surveillance

With the escalating overdose epidemic, many surveillance efforts have appeared. In 2018, King County Medical Examiner's Office (KCMEO) initiated a fatal overdose surveillance project aimed at expediting death certification and disseminating timely information. In this project, KCMEO investigators collected items of evidence of drug use from overdose death scenes, which were tested by five in-house methods, four using handheld devices: TruNarc Raman spectrometer, with and without the manufacture's H-Kit, Rigaku ResQ Raman spectrometer, and MX908 mass spectrometer. The fifth in-house method used fentanyl-specific urine test strips. Results from in-house testing were compared with results from Washington State Patrol (WSP) Materials Analysis Laboratory. From 2019 to 2022, there were 4244 evidence items of drugs and paraphernalia collected from 1777 deaths scenes. A total of 7526 in-house tests were performed on collected specimens, and 2153 tests were performed by the WSP laboratory using standard analytical methods. The WSP results served as reference standards to calculate performance metrics of the in-house methods. Sensitivities, specificities, and predictive values ranged from good to poor depending on the method, drug, and evidence type. Certain drugs were often associated with specific evidence types. Acetaminophen was frequently found in combination with fentanyl. Fentanyl test strips gave good scores for detecting fentanyl; otherwise, in-house methods using handheld devices had poor performance scores with novel drugs and drugs diluted in mixtures. The results showed that in-house testing of drug evidence has value for medical examiner overdose surveillance, but it is resource intensive, and success depends on collaboration with forensic laboratories.

Rapid Identification of Suspected Drug Overdose Deaths by Death Investigators, New Jersey, 2020

OBJECTIVE

While the number of overdoses in the United States continues to increase, lags in data availability have undermined efforts to monitor, respond to, and prevent drug overdose deaths. We examined the performance of a single-item mandatory radio button implemented into a statewide medical examiner database to identify suspected drug overdose deaths in near-real time.

MATERIALS AND METHODS

The New Jersey Office of the Chief State Medical Examiner operates a statewide mandated case management data system to document deaths that fall under the jurisdiction of a medical examiner office. In 2018, the New Jersey Office of the Chief State Medical Examiner implemented a radio button into the case management data system that requires investigators to report whether a death is a suspected drug overdose death. We examined the performance of this tool by comparing confirmed drug overdose deaths in New Jersey during 2020 with suspected drug overdose deaths identified by investigators using the radio button. To measure performance, we calculated sensitivity, specificity, positive predictive value, negative predictive value, and false-positive and false-negative error rates.

RESULTS

During 2020, New Jersey medical examiners investigated 26 527 deaths: 2952 were confirmed by the state medical examiner as a drug overdose death and 3050 were identified by investigators using the radio button as a suspected drug overdose death. Sensitivity was calculated as 96.1% (2837/2952), specificity as 99.1% (23 362/23 575), positive predictive value as 93.0% (2837/3050), negative predictive value as 99.5% (23 362/23 477), false-positive error rate as 7.0% (213/3050), and false-negative error rate as 3.9% (115/2952).

PRACTICE IMPLICATIONS

Implementation of a radio button into death investigation databases provides a simple and accurate method for identifying and tracking drug overdose deaths in near-real time.

Presentation and Outcomes of Adults With Overdose-Related Out-of-Hospital Cardiac Arrest

Importance

Drug overdose (OD) is a public health challenge and an important cause of out-of-hospital cardiac arrest (OHCA). Existing studies evaluating OD-related OHCA (OD-OHCA) either aggregate all drugs or focus on opioids. The epidemiology, presentation, and outcomes of drug-specific OHCA are largely unknown.

Objective

To evaluate the temporal pattern, clinical presentation, care, and outcomes of adult patients with OHCA overall and according to the drug-specific profile.

Design, Setting, and Participants

This cohort study of adults with OHCA in King County Washington was conducted between January 1, 2015, and December 31, 2021. Etiology of OHCA was determined using emergency medical service, hospital, and medical examiner records. Etiology was classified as non-OD OHCA or OD-OHCA, with drug-specific profiles categorized as (1) opioid without stimulant, (2) stimulant without opioid, (3) opioid and stimulant, or (4) all other nonstimulant, nonopioid drugs. Statistical analysis was performed on July 1, 2023.

Exposure

Out-of-hospital cardiac arrest.

Main Outcomes and Measures

The primary outcome was survival to hospital discharge. The secondary outcome was survival with favorable functional status defined by Cerebral Performance Category 1 or 2 based on review of the hospital record.

Results

In this cohort study, there were 6790 adult patients with emergency medical services-treated OHCA from a US metropolitan system. During the 7-year study period, there were 702 patients with OD-OHCA (median age, 41 years [IQR, 29-53 years]; 64% male [n = 450] and 36% female [n = 252]) and 6088 patients with non-OD OHCA (median age, 66 years [IQR, 56-77 years]; 65% male [n = 3944] and 35% female [n = 2144]). The incidence of OD-OHCA increased from 5.2 (95% CI, 3.8-6.6) per 100 000 person-years in 2015 to 13.0 (95% CI, 10.9-15.1) per 100 000 person-years in 2021 (P < .001 for trend), whereas there was no significant temporal change in the incidence of non-OD OHCA (P = .30). OD-OHCA were more likely to be unwitnessed (66% [460 of 702] vs 41% [2515 of 6088]) and less likely to be shockable (8% [56 of 702] vs 25% [1529 of 6088]) compared with non-OD OHCA. Unadjusted survival was not different (20% [138 of 702] for OD vs 18% [1095 of 6088] for non-OD). When stratified by drug profile, combined opioid-stimulant OHCA demonstrated the greatest relative increase in incidence. Presentation and outcomes differed by drug profile. Patients with stimulant-only OHCA were more likely to have a shockable rhythm (24% [31 of 129]) compared with patients with opioid-only OHCA (4% [11 of 295]) or patients with combined stimulant-opioid OHCA 5% [10 of 205]), and they were more likely to have a witnessed arrest (50% [64 of 129]) compared with patients with OHCA due to other drugs (19% [14 of 73]) or patients with combined stimulant-opioid OHCA (23% [48 of 205]). Patients with a combined opioid-stimulant OHCA had the lowest survival to hospital discharge (10% [21 of 205]) compared with patients with stimulant-only OHCA (22% [29 of 129]) or patients with OHCA due to other drugs (26% [19 of 73]), a difference that persisted after multivariable adjustment.

Conclusions and Relevance

In a population-based cohort study, the incidence of OD-OHCA increased significantly from 2015 to 2021, with the greatest increase observed among patients with a combined stimulant-opioid OHCA. Presentation and outcome differed according to the drug-specific profile. The combination of increasing incidence and lower survival among among patients with a opioid-stimulant OHCA supports prevention and treatment initiatives that consider the drug-specific profile.

Medical examiner response to the drug overdose epidemic in King County Washington: "Real-time" surveillance, data science, and applied forensic epidemiology

As the overdose epidemic overwhelmed medicolegal death investigation offices and toxicology laboratories, the King County Medical Examiner's Office responded with "real-time" fatal overdose surveillance to expedite death certification and information dissemination through assembling a team including a dedicated medicolegal death investigator, an information coordinator, and student interns. In-house testing of blood, urine, and drug evidence from scenes was performed using equipment and supplies purchased for surveillance. Collaboration with state laboratories allowed validation. Applied forensic epidemiology accelerated data dissemination. From 2010 to 2022, the epidemic claimed 5815 lives in King County; the last 4 years accounted for 47% of those deaths. After initiating the surveillance project, in-house testing was performed on blood from 2836 decedents, urine from 2807, and 4238 drug evidence items from 1775 death scenes. Time to complete death certificates decreased from weeks to months to hours to days. Overdose-specific information was distributed weekly to a network of law enforcement and public health agencies. As the surveillance project tracked the epidemic, fentanyl and methamphetamine became dominant and were associated with other indicators of social deterioration. In 2022, fentanyl was involved in 68% of 1021 overdose deaths. Homeless deaths increased sixfold; in 2022, 67% of 311 homeless deaths were due to overdose; fentanyl was involved in 49% and methamphetamine in 44%. Homicides increased 250%; in 2021, methamphetamine was positive in 35% of 149 homicides. The results are relevant to the value of rapid surveillance, its impact on standard operations, selection of cases requiring autopsy, and collaboration with other agencies in overdose prevention.

Evaluation of "Real-Time" Fatal Drug Overdose Surveillance by King County Medical Examiner's Office, Seattle, Washington

ABSTRACT

To address the challenges in monitoring the continuously accelerating drug overdose epidemic, the King County Medical Examiner's Office in Seattle, Washington, instituted a "real-time" fatal drug overdose surveillance project, depending on scene investigations, autopsy findings, and in-house testing of blood, urine, and drug evidence collected from death scenes. Validation of the project's rapid death certification methodology from 2019 through 2021 was performed at the following 3 levels: blood testing, urine testing, and death certification, and for the following 4 drugs: fentanyl, opiate, methamphetamine, and cocaine. For blood testing, sensitivity ranged from 90% to 99%, and specificity ranged from 86% to 97%. For urine testing, sensitivity ranged from 91% to 92%, and specificity ranged from 87% to 97%. The positive predictive value for cocaine was poor for both blood testing (57%) and urine testing (72%). Of 1034 deaths, 807 were certified as overdose by rapid methodology, and 803 (99.5%) were confirmed by formal toxicology results. Manners of death were changed from accident to natural in 3 of 1034 cases (0.29%). Results of this study indicate that the rapid overdose surveillance methodology described in this study offers benefits to families and provides useful, timely information for responding law enforcement and public health agencies.