Drugs involved in Kentucky drug poisoning deaths and relation with antecedent controlled substance prescription dispensing.

BACKGROUND: The shift from prescription to illicit drugs involved in drug poisoning deaths raises questions about the current utility of prescription drug monitoring program (PDMP) data to inform drug poisoning (overdose) prevention efforts. In this study, we describe relations between specific drugs involved in Kentucky drug poisoning deaths and antecedent controlled substance (CS) dispensing. METHODS: The study used linked death certificates and PDMP data for 2,248 Kentucky resident drug poisoning deaths in 2021. Death certificate literal text analysis identified drugs mentioned with involvement (DMI) in drug poisoning deaths. We characterized the concordance between each DMI and the CS dispensing history for this drug at varying timepoints since 2008. RESULTS: Overall, 25.5% of all decedents had dispensed CS in the month before fatal drug poisoning. Over 80% of decedents were dispensed opioid(s) since 2008; the percentage was similar regardless of opioid involvement in the poisoning death. One-third of decedents had dispensed buprenorphine for treatment of opioid use disorder since 2008, but only 6.1% had dispensed buprenorphine in the month preceding death. Fentanyl/fentanyl analogs were DMI in 1,568 (69.8%) deaths, yet only 3% had received a fentanyl prescription since 2008. The highest concordance in the month preceding death was observed for clonazepam (43.6%). CONCLUSION: Overall, concordance between CS dispensing history and the drugs involved in poisoning deaths was low, suggesting a need to reevaluate the complex relationships between prescription medication exposure and overdose death and to expand harm reduction interventions both within and outside the healthcare system to reduce drug poisoning mortality.

Changing Trends in Drug Overdose Mortality in Kentucky: An Examination of Race and Ethnicity, Age, and Contributing Drugs, 2016-2020.

OBJECTIVES: Increased drug overdose mortality among non-Hispanic Black people in the United States in the past 5 years highlights the need for better tailored programs and services. We evaluated (1) changes in drug overdose mortality for various racial and ethnic groups and (2) drug involvement to inform drug overdose prevention efforts in Kentucky. METHODS: We used Kentucky death certificates and postmortem toxicology reports from 2016-2020 (provisional data) to estimate changes in age-adjusted drug overdose death rates per 100 000 standard population. RESULTS: The age-adjusted drug overdose death rate per 100 000 standard population among non-Hispanic Black residents doubled from 2016 (21.2) to 2020 (46.0), reaching the rate among non-Hispanic White residents in 2020 (48.7; P = .48). From 2016 to 2020, about 80% of these drug overdose deaths involved opioids; heroin involvement declined about 20 percentage points; fentanyl involvement increased about 30 percentage points. The number of psychostimulant-involved drug overdose deaths increased 513% among non-Hispanic Black residents and 191% among non-Hispanic White residents. Cocaine-involved drug overdose deaths increased among non-Hispanic Black residents but declined among non-Hispanic White residents. Drug overdose death rates were significantly lower among Hispanic residents than among non-Hispanic White residents. CONCLUSIONS: Increased opioid-involved overdose deaths among non-Hispanic Black residents in Kentucky in combination with rapidly expanding concomitant psychostimulant involvement require increased understanding of the social, cultural, and illicit market circumstances driving these rapid trend changes. Our findings underscore the urgent need to expand treatment and harm reduction services to non-Hispanic Black residents with substance use disorder.

Impact of a Drug Overdose Decedent Toxicology Testing Legislative Mandate on Informing Coroner Death Investigation and Certification Practices.

OBJECTIVE: To (a) determine the impact of Kentucky's (KY's) mandate requiring postmortem toxicology testing of coroner cases; (b) identify the influence of coroner experience and training, jurisdiction size, budget, and location on postmortem testing requests; (c) identify facilitators/barriers for postmortem toxicology testing requests and listing the specific drugs involved in drug-poisoning deaths on death certificates. METHODS: A modified Dillman approach was used to deliver the survey to KY's elected coroners between April and May 2016. Responses stratified by identified influence factors were compared using χ2 tests and Fisher exact tests. RESULTS: Fifty-eight percent of coroners reported that drug overdose investigations had changed since the mandate was enacted. Statistically significant differences in responses were found when stratified. Sixty-three percent of coroners reported always using testing results to complete death certificates. CONCLUSIONS: Uptake of the mandate for postmortem toxicology testing of all decedents is not yet complete. POLICY IMPLICATION: Without uptake of the mandate, surveillance efforts may result in undercounting of drug overdose deaths and the involvement of specific drugs. Mandates for enhanced training and modification of funding structure for medico-legal death investigations could facilitate uptake.

Establishment of a comprehensive drug overdose fatality surveillance system in Kentucky to inform drug overdose prevention policies, interventions and best practices.

BACKGROUND: According to the National Center for Health Statistics, Kentucky had the third highest drug overdose fatality rate in the nation in 2015 at 29.9 drug overdose fatalities per 100 000 population. OBJECTIVE: The elevated drug overdose fatality rate necessitated the development and implementation of a comprehensive multisource drug overdose fatality surveillance system (DOFSS). METHODS: DOFSS stakeholder work group members and data sources were identified, and memorandums of understanding were established. The following data sources were used to establish DOFSS: (1) death certificates; (2) autopsy reports; (3) toxicology result reports; (4) coroner reports; and (5) Kentucky All Schedule Prescription Electronic Reporting (KASPER) (prescription drug monitoring programme) data. Drug overdose poisonings were defined using Injury Surveillance Workgroup 7 definitions. Analyses were performed to investigate possible drug overdose-related health disparities for disabled drug overdose decedents and to characterise gabapentin in drug overdose deaths. RESULTS: DOFSS identified 2106 drug overdose poisoning fatalities in Kentucky for 2013-2014. Identification of specific drugs involved in drug overdose deaths increased from 75.8% using a single data source to 97.5% using multiple data sources. Disabled drug overdose decedents were significantly more likely to have an active prescription for drugs identified in their system compared with the non-disabled drug overdose decedents. Toxicology data showed increased gabapentin involvement in drug overdose deaths from 2.9% in 2013 to 17% in 2014. Alprazolam was found most often in combination with gabapentin (41%), along with various other benzodiazepines and prescription opioids. CONCLUSIONS: A comprehensive multisource DOFSS improved drug overdose fatality surveillance by increasing completeness of data and data quality. DOFSS is a model that can be considered by other states to enhance their efforts in tracking drug overdose fatalities, identifying new and emerging trends, and informing policies and best practices, to address and reduce drug overdoses.

Heroin and fentanyl overdoses in Kentucky: Epidemiology and surveillance.

BACKGROUND: The study aims to describe recent changes in Kentucky's drug overdose trends related to increased heroin and fentanyl involvement, and to discuss future directions for improved drug overdose surveillance. METHODS: The study used multiple data sources (death certificates, postmortem toxicology results, emergency department [ED] records, law enforcement drug submissions, and prescription drug monitoring records) to describe temporal, geographic, and demographic changes in drug overdoses in Kentucky. RESULTS: Fentanyl- and heroin-related overdose death rates increased across all age groups from years 2011 to 2015 with the highest rates consistently among 25-34-year-olds. The majority of the heroin and fentanyl overdose decedents had histories of substantial exposures to legally acquired prescription opioids. Law enforcement drug submission data were strongly correlated with drug overdose ED and mortality data. The 2016 crude rate of heroin-related overdose ED visits was 104/100,000, a 68% increase from 2015 (62/100,000). More fentanyl-related overdose deaths were reported between October, 2015, and September, 2016, than ED visits, in striking contrast with the observed ratio of >10 to 1 heroin-related overdose ED visits to deaths. Many fatal fentanyl overdoses were associated with heroin adulterated with fentanyl; <40% of the heroin overdose ED discharge records listed procedure codes for drug screening. CONCLUSIONS: The lack of routine ED drug testing likely resulted in underreporting of non-fatal overdoses involving fentanyl and other synthetic drugs. In order to inform coordinated public health and safety responses, drug overdose surveillance must move from a reactive to a proactive mode, utilizing the infrastructure for electronic health records.