The Office of the Chief Medical Examiner, Virginia Department of Health

Deaths from Heroin and Prescription Opiates in Virginia:

An Overview

William T. Gormley, MD, PhD, Chief Medical Examiner

Rosie Hobron, MPH, Forensic Epidemiologist

Data Sources: Office of the Chief Medical Examiner, Virginia Medical

Examiner Data System (VMEDS)

Office of the Chief Medical Examiner

Code of Virginia § 32.1-283 Investigation of deaths: obtaining consent to removal of organs, etc.; fees

Deaths from Heroin and Prescription Opiates

20042005200620072008200920102011201220132014*

0

50

100

150

200

250

0 4

19

10089

107

48

100

135

213 210

Number of Fatal Heroin Overdoses by Year,

2004-2014*

Year

Num

ber

of

Death

s

1 Fatal heroin overdoses may have one or more drug or poisons con-tributing to death.2 The number of fatal heroin overdoses in 2014 is estimated based upon data for January 1, 2014 to June 30, 2014.

2007 2008 2009 2010 2011 2012 2013 20140

100

200

300

400

500

600

389

422398

415

487

414

468

508

Number of Fatal Prescription Opioid Overdoses by Year, 2007-2014*

Year

Num

ber

of

Death

s

1 Heroin and prescription drug deaths are tallied separately. Where heroin and prescription opioids caused or contributed to death, dece-dents will be counted twice.2 Prescription opioid deaths are drug/poison deaths where one or more prescription opioids caused or contributed to death.3 The number of fatal heroin overdoses in 2014 is estimated based upon data for January 1, 2014 to June 30, 2014.

<1 1-4 5-9 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ <1 1-4 5-9 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

Fentanyl *

0 0 0 0 1 11 30 26 22 9 0 0 0

Heroin *

0 0 0 0 4 22 76 57 37 13 4 0 0

Opiate Prescription Drugs *

0 0 1 0 2 24 105 80 93 52 14 3 2

Total Drug Deaths +

0 0 0 0 4 22 76 57 37 117 26 5 5

10

30

50

70

90

110

130

10

30

50

70

90

110

130

Total Number of Fentanyl, Heroin, and Opiate Prescription Drugs Causing or Contributing to Death by Age Group, 2013

Num

ber o

f D

rugs D

etected

Num

ber o

f D

eaths

* Deaths due to fentanyl, heroin, and opiate prescription drug overdoses are tallied by the drugs causing or contributing to death. Fatalities involving more than one of these drugs will be represented more than once in the relevant age group.+Total drug deaths represent all fatalities due to drugs and are counted as one occurrence, even though one or more drugs caused or contributed to that death.

FEMALE42.2%

MALE57.8%

Percentage of Fatal Heroin Drug Overdoses by Gender, 2013

FEMALE31.4%

MALE68.6%

Percentage of Fatal Opiate Prescription Drug Overdoses by Gender, 2013

Heroin and Prescription Opiates

Heroin under-represented• Heroin is Morphine Pro-drug• Diagnosis of Heroin COD

• 6-Acetyl Morphine• Circumstances

Opiates – prescription vs. illicit• Medical Records• Scene and circumstances

Heroin3,6 Diacetyl Morphine

6-Acetyl Morphine

Morphine

Inactive Metabolites

T ½2-3 min

T ½< 5 min

T ½2-3 hours

Definition

Half LifeThe length of time it takes the concentration of a drug in the blood to decrease to ½ of its current value

Time

0

20

40

60

80

100

120

T1/2 = 1T1/2 = 2

Heroin

• Diacetyl (3,6) Morphine

• T ½ 2-3 min• Inactive but rapidly

converted to morphine• Liver – glucuronide –

kidney• RUSH occurs while

conversion to 6-MAM and morphine in brain

6-acetyl morphine

Monoacetyl morphine• T ½ less than 5 min• Psychoactive

metabolite, somewhat more potent than morphine

• May be responsible for RUSH

Greater histamine release than morphine when IV

Morphine

• T ½ 2 – 3 hours• Liver – glucuronide

- kidney

Heroin3,6 Diacetyl Morphine

6-Acetyl Morphine

Morphine

Inactive Metabolites

T ½2-3 min

T ½< 5 min

T ½2-3 hours

Heroin

• > 20% average annual increase over decade

• 35% increase from 2011 to 2012

• 58% increase from 2012 to 2013

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

*0

50

100

150

200

250

0 4

19

10089

107

48

100

135

213 210

Number of Fatal Heroin Overdoses2004-2014*

Year

Num

ber

of

Death

s

1 Fatal heroin overdoses may have one or more drug/poisons contributing to death.2 The number of fatal heroin overdoses in 2014 is estimated based upon six months of data for Janu-ary 1, 2014 to June 20, 2014.

Opiates – Prescription vs. illicit

Prescription Opiate Drugs

• 4 % average annual increase over 7 years

• 13% increase from 2012 to 2013

• 9% projected increase from 2013 to 2014

2007 2008 2009 2010 2011 2012 2013 20140

100

200

300

400

500

600

389422

398415

487

414

468

508

Number of Fatal Prescription Opiod Overdoses by Year, 2007-2014*

Year

Num

ber

of

Death

s

1 Heroin and prescription drug deaths are tallied separately. Where heroin and prescription opioids caused or contributed to death, dece-dents will be counted twice.2 Prescription opioid deaths are drug/poison deaths where one or more prescription opioids caused or contributed to death.3 The number of fatal prescription opiod overdoses in 2014 is estimated based upon data for January 1, 2014 to June 30, 2014.

Heroin and Prescription Opioids

Codei

ne

Heroi

n

Hydro

codo

ne

Hydro

mor

phon

e

Fent

anyl

Metha

done

Morph

ine

Oxyco

done

Oxym

orph

one

0

20

40

60

80

100

120

140

160

180

200

11

36

69

40

102 104

85

180

52

Number of Opioid Drugs Causing or Contributing to Death in Fatal Prescription Opioid Overdoses (n=468), 2013

Opioid Drug

Num

ber

of

Dru

gs

1 Prescription opiod deaths may have more than 1 opiod causing or contributing to death2 Morphine is not reported for heroin deaths due to it being a metabolite of heroin

Heroin and Prescription Opiate Drugs

2007 2008 2009 2010 2011 2012 2013 20140

100

200

300

400

500

600

100 89107

48

100

135

213 210

389

422398

415

487

414

468

508

Number of Fatal Heroin and Prescription Opiate Overdoses by Year, 2007-2013

Heroin

Prescription Opiods

Year

Num

ber

of

Death

s

1 Heroin and prescription drug deaths are tallied separately. Where heroin and prescription opioids caused or contributed to death, dece -dents will be counted twice.2 Prescription opioid deaths are drug/poison deaths where one or more prescription opioids caused or contributed to death.3 The number of fatal heroin and prescription opiod overdoses in 2014 is estimated based upon data for January 1, 2014 to June 30, 2014.

From 2007-2013, nearly 70% of all drug/poison deaths were

attributed to opiates.

Surveillance Roles

Situational Awareness• Monitor death incidence as close to real time

as possible.• Forecast and warn public.

Prevention• Identify strategies.• Evaluate and document result of strategy

implementation.

Surveillance Data

OCME Death data delayed by 3 to 6 monthsOther data streams include:

• Hospital and ER admissions – VDH• Law enforcement drug seizures – DFS• Law enforcement intelligence – i.e. Fusion• Prescription Monitoring Program (PMP)

SummaryHeroin under-represented

• Heroin is Morphine Pre-drug• Diagnosis of Heroin COD

• 6-Acetyl Morphine• Circumstances

Opiates – prescription vs. illicit• Medical Records• Scene and circumstances

General increase in deaths from both over the last decade.• Heroin approximately 20% per year, 35% in 2012, >50% in

2013• Prescription opiates approximately 10% per year, 15% in 2012

Surveillance• Situational Awareness• Identify Prevention Strategies• Evaluate Prevention Strategies