Tracking the Opioid Drug Overdose Epidemic in King County, Washington Using an Improved Methodology for Certifying Heroin Related Deaths

Guidelines of the National Association of Medical Examiners recommend that death certificates of overdose deaths list specific drugs. While this is important in tracking the national opioid drug overdose epidemic, differentiating heroin from morphine as the source drug remains problematic. To distinguish the two, a specific methodology was developed for death certification based on a combination of toxicology testing and scene investigation. This study evaluates the methodology in assessing the contribution of heroin. In two decades in King County, there were 3369 opioid drug overdose deaths, ranging from 139 in 1995 to 233 in 2014. In the 1990's, opioid overdose deaths were predominantly due to heroin; deaths due to prescription opioids were relatively uncommon. This trend reversed around 2003 with overdose deaths due to heroin declining and those due to prescription opioids increasing. The trend again reversed around 2012 with resurgence of heroin and declining deaths due to prescription opioids. Before the specific methodology was employed, it was known that heroin was the predominant opioid, but the summary data did not differentiate morphine and heroin. After adopting the methodology in 2004, the data reasonably tracked the contribution of heroin: out of 2125 opioid deaths, 34% were due to heroin, ranging from 14% in 2009 to 65% in 2014. The results of this study show an overall increase in opioid deaths and an inverse relationship between heroin and the prescription opioids. Furthermore, the specific methodology for certifying heroin deaths greatly improves accuracy in tracking opioid overdose deaths.

The Cuyahoga County Heroin Epidemic

Cuyahoga County, Ohio has recently seen a dramatic rise in the number of deaths associated with heroin (DAH). DAH rose from 40 in 2007 to 161 in 2012 with heroin now identified in half of all overdose deaths. One third of DAH involve heroin alone; the remainder, in combination with other drugs. Over this period, opioid pain reliever (OPR) deaths appear to have plateaued.

Along with this rise have been shifts in overdose victim demographics. These data most notably include a rise in the number of women (from 15% to 24%), overdoses between the ages 19 and 29 (8% to 25%), and a generally equal number of urban and suburban fatalities.

The Medical Examiner's Office conducted a retrospective analysis of 2012 fatalities to identify potential risk factors and intervention points. This review indicates that most victims (81%) were known to abuse drugs. Half were found with drug paraphernalia at the scene. Approximately 12% were using heroin with other addicts, while 60% were using drugs or succumbed to them in proximity to other non-using people. Emergency medical services were only able to administer naloxone in 22% of cases. Histories of recent abstinence (29%), incarceration (18%), and detoxification (31%) were noted and may reflect times of increased risk secondary to decreased tolerance. A prescription for legal controlled substances was noted in 64% of DAH (the most common medications being OPRs and benzodiazepines). This suggests a need to address prescribing practices. Public health interventions, implemented or planned, based on these data are discussed.