heroin indicators report highlights - tennessee indicators report highlights march 2017 ellen...

Heroin Indicators Report Highlights

March 2017 Ellen Omohundro, PhD

Office of Research, 3/15/2017

Executive summary Successes • Both the number of prescriptions and quantity of opioids

prescribed are decreasing. Challenges • Opioid crimes, especially heroin crimes, are on the rise. • Injection drug use is increasing. • Most drug overdose deaths are opioid related, especially

opioids in combination with benzodiazepines. Community impacts • Opioid abuse is highest in rural counties and small towns. • Heroin abuse is spreading from urban to suburban areas. • Heroin poisoning hospitalizations are increasing while opioid

poisoning hospitalizations have dropped slightly since 2011. • Over 1,000 babies experienced withdrawal from drug exposure

prior to birth in 2014 and 2015.

E. Omohundro, PhD, 3/15/2017 Office of Research 2

OPIOID SUPPLY

3 E. Omohundro, PhD, 3/15/2017

Office of Research

Opioid prescriptions are decreasing.

395,000 fewer opioid prescriptions

reported to the CSMD in 2015 compared to

the peak in 2012

4

8.93 8.88 8.78 8.53

3.94 3.98 4.09 4.01

3.61 3.64 3.48 3.42

1.25 1.32 1.40 1.47 0

2

4

6

8

10

CY 2012 CY 2013 CY 2014 CY 2015

Num

ber o

f pre

scrip

tions

(in

mill

ions

)

Opioids Benzodiazepines Other Stimulants

Number of controlled substance prescriptions written to Tennessee patients (in millions) and reported to the Controlled Substance Monitoring Database: 2012-2015

Source: Tennessee Department of Health, CSMD Annual Report to the Legislature, February 1, 2016 Note: Excludes prescriptions from methadone opioid treatment programs and prescriptions reported from VA pharmacies.

E. Omohundro, PhD, 3/15/2017 Office of Research

DeKalb

Grundy Sequatchie

Opioid prescriptions are decreasing most in east Tennessee.

5

Opioid prescriptions per 1,000 population 2012

2015

Source: Tennessee Department of Health, January 12, 2017. Note: Excludes prescriptions from methadone opioid treatment programs and prescriptions reported from VA pharmacies.

DeKalb

Grundy Sequatchie

Prescriptions per 1k

Prescriptions per 1k


8,792

649

8,562

847

8,082

1,064

7,536

1,134

0

2,000

4,000

6,000

8,000

10,000

MM

Es (i

n m

illio

ns)

2012 2013 2014 2015

MMEs Opioids for Pain2 MMEs Opioids for Treatment of Addiction3,4

The quantity of MMEs prescribed for pain decreased. MMEs prescribed for the treatment of addiction increased.

Amount of morphine milligram equivalents (MMEs)1 dispensed to Tennessee patients (in millions) and reported to the Controlled Substance Monitoring Database: 2012-2015

Source: Tennessee Department of Health, CSMD Annual Report to the Legislature, February 1, 2016 Notes: (1) MMEs are reported per million (unit = 1,000,000 MMEs); (2) includes prescription opioids for pain and treatment; (3) excludes FDA approved buprenorphine products indicated for treatment of opioid dependence and prescriptions reported from VA pharmacies; (4) excludes prescriptions from methadone opioid treatment programs and prescriptions reported from VA pharmacies.

14% drop in MMEs

for PAIN from 2012 to 2015

75% increase in MMEs

for ADDICTION TREATMENT from 2012 to 2015


Office of Research

The percent of users on a high daily dose of opioids (>90 MME) decreased from 2012 to 2015.

7

Percentage of opioid users with an average daily MME >90

2012

2015

Source: Tennessee Department of Health, January 12, 2017. Note: Excludes prescriptions from methadone opioid treatment programs and prescriptions reported from VA pharmacies.

Unicoi

Morgan

Roane Cocke

Jefferson

Claiborne Campbell

Union Grainger

Percent MME >90

Percent MME >90


CRIME Opioid & Heroin Trends


Office of Research

Opioid- and heroin- related crimes increased. Heroin seizures increased but opioid seizures decreased.

Number of people arrested1, 2009-2016

Source: Tennessee Bureau of Investigation (TBI) CJIS Support Center, 2009-2016, Lab data 2009-2015. Notes: (1) Includes expunged records. (2) Opioid-related arrests include arrests for morphine, opium, and all narcotic-related arrests with the exception of cocaine and crack-cocaine arrests. Arrestees were only counted once if more than one type of narcotic was present.

9

5,398

7,149 6,896

169 360

1,516

0

2,000

4,000

6,000

8,000

2009 2010 2011 2012 2013 2014 2015 2016

Num

ber o

f Peo

ple

arre

sted

Opioids Heroin2

5,580

6,858

4,585

82 120 599

0

2,000

4,000

6,000

8,000

2009 2010 2011 2012 2013 2014 2015

Num

ber o

f dru

g se

izure

s

Opioids Heroin2

797%

630%

28%

18%

Number of confirmed drug seizures, 2009-2015


0.57

4.30 1.37

1.07 0.25

0

5

10

15

20

2009 2010 2011 2012 2013 2014 2015 2016

Rate

per

10k

pop

ulat

ion

Metro countiesSuburbanSmall townsRural

Opioid-related crimes are highest in small towns and rural areas. Heroin-related crimes are highest in urban areas.

Number of people arrested6 (per 10K population) by area: Tennessee, 2009-2016

10

Notes: (1) Metro counties: The most densely

populated counties were examined as a group and are: Shelby, Davidson, Knox, and Hamilton counties.

(2) Suburban: Metropolitan Statistical Areas have an urban cluster with a population of 50,000 or more.

(3) Small towns: Micropolitan Statistical Areas have an urban cluster with a population at least 10,000 but less than 50,000.

(4) Rural: not a metro or micropolitan county.

(5) Opioid-related arrests include arrests for morphine, opium, and all narcotic-related arrests with the exception of cocaine and crack-cocaine arrests. Arrestees were only counted once if more than one type of narcotic was present.

(6) Includes expunged records.

Source: Tennessee Bureau of Investigation CJIS Support Center, 2009-2016

4

1

2

3


11.36

16.34

12.03 13.82

9.14

11.31

5.79

6.53

0

5

10

15

20

2009 2010 2011 2012 2013 2014 2015 2016

Rate

per

10k

pop

ulat

ion

Small towns

Rural

Suburban

Metro counties1

2

3

4

Opioids5

Heroin

Clay

Van Buren

Grundy

Smith

Picket Scott Campbell

Union Trousdale

Roane

Rhea

Opioid-related arrests are highest in east Tennessee.

Number of people arrested for opioid-related crimes (per 10K population)

2009-2010

2015-2016

11

Source: Tennessee Bureau of Investigation (TBI) CJIS Support Center, 2009-2016

Notes: Rates are only shown for counties where the combined count during the time period was 5 or greater. Rates based on two year averages. Opioids exclude heroin.

Clay

Campbell Trousdale Fentress Claiborne

DeKalb

Anderson Unicoi

Wayne

Scott

People arrested per 10k



Heroin-related arrests continue to increase in counties around urban areas.

Number of people arrested for heroin-related crimes (per 10K population)

2009-2010

2015-2016

12

Source: Tennessee Bureau of Investigation (TBI) CJIS Support Center, 2009-2016

Notes: Rates are only shown for counties where the combined count during the time period was 5 or greater. Rates based on two year averages. Opioids exclude heroin.

Madison

Davidson

Cheatham

Knox

Sevier

Shelby

Sumner

Tipton




Opioid drug seizures decreased in 2014-2015 but are still concentrated in east Tennessee.

Source: Tennessee Bureau of Investigation (TBI) lab data, 2009-2015. Notes: Rates are only shown for counties where the combined count during the time period was greater than 5. (1) Opioids exclude heroin & buprenorphine.

13

2014-2015

Seizures per 10k

TBI confirmed opioid1 drug seizures (per 10K population)

2009-2010

Humphreys

Smith

Clay

Cocke

Campbell Claiborne

Seizures per 10k


Heroin drug seizures increased in counties around urban areas.

Source: Tennessee Bureau of Investigation (TBI) lab data, 2009-2015. Notes: Rates are only shown for counties where the combined count during the time period was greater than 5.

14

TBI confirmed heroin seizures (per 10K population)

2009-2010

Seizures per 10k

2014-2015

Seizures per 10k


POISONING Heroin and

other opioids 15


Hospitalizations for heroin poisoning increased (641%) from 2009 to 2014. Opioid poisoning increased (1.4%).

16

Number of hospital discharges1 for opioid and heroin poisonings: Tennessee 2009-2014

5,334 5,423

5,883 5,783 5,435 5,409

66 76 131 216 311 489

0

1,000

2,000

3,000

4,000

5,000

6,000

2009 2010 2011 2012 2013 2014

Num

ber o

f dru

g po

ison

ings

Calendar Year

Opioids Heroin2 3

Source: Tennessee Department of Health, 2009-2014. Notes: (1) The data represents all

outpatient (emergency room visits and 23-hour observations) and inpatient (stays of 24-hours or longer) hospital discharges of Tennessee residents. All 18 diagnoses and all three external cause on injury (e-codes) were evaluated.

(2) Opioid poisonings include hospital discharges with ICD-9 codes of 965.09, E850.2, E935.2.

(3) Heroin poisonings include hospital discharges with ICD-9 codes of 965.01, E850.0, E935.0.

Opioid hospitalizations increased 1.4% between 2009 and 2014

Heroin hospitalizations increased 641% between 2009 and 2014


Hospitalizations for heroin poisonings are higher in the west while opioid poisonings are higher in the east.

17

Benton

Giles

Jackson Overton Fentress

Cannon

Grundy

Warren

Claiborne

Hancock

DeKalb

Davidson

Cheatham

Fayette

Tipton

Shelby

Notes: (1) The data represents all outpatient (emergency room visits and 23-hour observations) and inpatient (stays of 24-hours or longer) hospital discharges of Tennessee residents. All 18 diagnoses and all three e-codes were evaluated. (2) Heroin poisonings include hospital discharges with ICD-9 codes of 965.01, E850.0, E935.0. (3) Opioid poisonings include hospital discharges with ICD-9 codes of 965.09, E850.2, E935.2.

Hospital discharges1 for drug poisonings (per 10K population), 2012-2014

Opioids

Discharges per 10k


Discharges per 10k

Hancock

DeKalb

Davidson Cheatham

Fayette

Tipton

Shelby

Heroin

Source: Tennessee Department of Health, 2012-2014.

Heroin- and opioid-related deaths are increasing, especially when opioids are combined with benzodiazepines.

18

Notes: • Not all drug overdose deaths specify the drug(s) involved, and a death may involve more than one specific substance. • Increases in overdose deaths may be due to increases in reporting by medical examiners. 1) All drug overdose deaths are based on the following ICD-10 underlying cause of death codes: X40-X44, X60-X64, X85, Y10-Y14. 2) “All opioids" overdose deaths were summarized based on an underlying cause of death being a drug overdose and the multiple causes of death containing at least one of the

following ICD-10 codes: T40.0-T40.4, T40.6. 3) "Heroin" overdose deaths were summarized based on an underlying cause of death being a drug overdose and the multiple causes of death containing at least one of the following

ICD-10 codes: T40.1. 4) “Methadone” overdose deaths were summarized based on an underlying cause of death being a drug overdose and the multiple causes of death containing ICD-10 code: T40.3. 5) "Opioids with benzodiazepine" overdose deaths were summarized based on an underlying cause of death being a drug overdose and the multiple causes of death containing at least

one of the following ICD-10 codes: T40.0-T40.4, T40.6 in addition to T42.4.

2

71% of drug overdose deaths are opioid-related

1,094 1,168

1,263

1,451

698 756 861

1,034

249 342 346

447

45 63

147 205 101 87

71 67 0

200

400

600

800

1,000

1,200

1,400

2012 2013 2014 2015

Ove

rdos

e de

aths

All drugs All opioids Opioids with benzodiazepine Heroin Methadone3 5 2 4

Source: Tennessee Department of Health, 2012-2015

Heroin 355% increase

Opioid-related deaths increased 48%

(includes heroin & other opioids)

Methadone 34% decrease

Opioids with benzodiazepine 80% increase


1

Tennessee opioid-involved death rates are higher than the United States.

2.3 3.4

8.6

3.8

2.1 1.8 1.1 1.1

3.3 4.1

9.7

3.9 4.0 3.1

1.0 1.0

0.0

2.0

4.0

6.0

8.0

10.0

12.0

TN U.S. TN U.S. TN U.S. TN U.S.

Heroin Natural/Semisynthetic Synthetic Methadone

Age

adju

sted

rate

per

100

,000

pop

ulat

ion

Drug overdose deaths involving opioids 2014 2015

Tennessee death rates for natural/semisynthetic opioids are more than 2x the U.S.

Source: MMWR, Early Release, December 16, 2016, CDC.

19

Tennessee death rates involving… Heroin increased 44% Natural and semisynthetic opioids increased 13% Synthetic opioids increased 91% Methadone did not change


Davidson

Tipton

Shelby

Dickson

Opioid overdose deaths are primarily in rural areas; heroin overdose deaths are in urban areas.

20

Source: Tennessee Department of Health, 2013-2015

Deaths per 10k

Drug overdose deaths (per 10K population), 2013-2015


Hardin

Benton Deaths per 10k

Opioids

Heroin

Notes: • Not all drug overdose deaths specify the drug(s) involved, and a death may involve more than one specific substance. • Increases in overdose deaths may be due to increases in reporting by medical examiners. 1) “All opioids" overdose deaths were summarized based on an underlying cause of death of at least one of the following ICD-10 codes: X40-X44, X60-X64, X85, Y10-Y14 and the multiple

causes of death containing at least one of the following ICD-10 codes: T40.0-T40.4, T40.6. 2) "Heroin" overdose deaths were summarized based on an underlying cause of death of at least one of the following ICD-10 codes: X40-X44, X60-X64, X85, Y10-Y14 and the multiple causes of

death containing T40.1.

Jackson

Morgan

Rhea

Campbell

Hamblen Grainger

Hancock Hawkins

Greene

Sullivan

Carter

Unicoi

Unique cases of Neonatal Abstinence Syndrome (NAS) are stable.

21

Notes: 1) Tennessee Department of Health, Neonatal Abstinence Syndrome

Surveillance System, provided number of NAS cases, 2013-2015 and readers are advised to interpret small numbers with caution. Please contact Angela M. Miller, PhD, MSPH,([email protected]) if you need assistance in interpreting the NAS data.

2) Tennessee Department of Health, Division of Policy, Planning and Assessment provided number of live births 2013-2015.

Number of unique cases of NAS and live births: Tennessee 2013-2015

YearNumber of NAS Cases

(% of live births)1 Number of Live Births2

2013 936 (1.17%) 79,9542014 1,031 (1.26%) 81,6092015 1,041 (1.28%) 80,900

Unique cases1 of NAS per 1,000 live births2: 2013-2015

Unique cases1 of Neonatal Abstinence Syndrome (NAS): Tennessee 2013-2015

936 1,031 1,041

0

200

400

600

800

1,000

2013 2014 2015

Num

ber o

f NAS

cas

es

Calendar Year

Cases per 1k births


mailto:[email protected]

TREATMENT Opioid, heroin, injection drug use


Office of Research

TDMHSAS treatment admissions for opioids are declining but heroin admissions are increasing.

23

Source: Tennessee Department of Mental Health and Substance Abuse Services WITS, FY 2011-FY 2016 Notes: (1) TDMHSAS-funded substance abuse treatment admissions only include treatment admissions for Tennessee residents age 12 and older, below the 133% poverty line and have no insurance for which there was a bill. Up to three substances can be listed for each treatment admission. (2) opioid treatment admissions include any mention of opioids or methadone; (3) Heroin admissions include any mention of heroin.

Number of opioid and heroin substance abuse treatment admissions1 funded by Tennessee Department of Mental Health and Substance Abuse Services (TDMHSAS): FY 2011-FY 2016

5,245 5,671

6,194 6,166 6,158 6,025

313 397 627 765 1,135

1,607

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

FY 2011 FY 2012 FY 2013 FY 2014 FY 2015 FY 2016

Num

ber o

f adm

issio

ns

Opioid2 admissions are declining but are 15% higher than FY 2011 levels

Heroin3 admissions increased 414%


Number of opioid and heroin substance abuse treatment admissions1 funded by TDMHSAS: FY 2011-FY 2016

Year (CY) FY 2011 FY 2012 FY 2013 FY 2014 FY 2015 FY 2016

Opioids2 5,245(37.6%) 5,671 (39.9%) 6,194 (41.3%) 6,166 (40.8%) 6,158 (41.5%) 6,025 (39.1%) Heroin3 313 (2.2%) 397 (2.8%) 627 (4.2%) 765 (5.1%) 1,135 (7.7%) 1,607 (10.4%) Total 13,967 14,225 14,986 15,123 14,823 15,395 Note: Count (% of total admissions)

TDMHSAS treatment admissions for heroin and opioids are greatest for ages 25-44.

24

Heroin

Ages 25-44 484%

Ages 18-24 308%

Opioids

Ages 25-44 35%

Ages 18-24 62%

132.6

71.1

133.1 158.3

0

25

50

75

100

125

150

FY 2011 FY 2012 FY 2013 FY 2014 FY 2015 FY 2016

Rate

per

10k

pov

erty

pop

ulat

ion

Opioids3

12-17 18-24 25-44 45+

6.6

23.6 8.3

42.8

0

25

50

75

100

125

150

FY 2011 FY 2012 FY 2013 FY 2014 FY 2015 FY 2016

Rate

per

10k

pov

erty

pop

ulat

ion

Heroin2

12-17 18-24 25-44 45+


Source: Tennessee Department of Mental Health and Substance Abuse Services WITS, FY 2011-FY 2016 Notes: (1) TDMHSAS-funded substance abuse treatment admissions only include treatment admissions for Tennessee residents age 12 and older, below the 133% poverty line and have no insurance for which there was a bill. Up to three substances can be listed for each treatment admission. (2) Heroin admissions include any mention of heroin. (3) Opioid treatment admissions include any mention of opioids or methadone.

TDMHSAS treatment admissions1 (per 10K poverty population) by age group: FY 2011-FY 2016

35.0

47.2

21.6

47.5

0

15

30

45

60

75

90

FY 2011 FY 2012 FY 2013 FY 2014 FY 2015 FY 2016

Rate

per

10k

pov

erty

pop

ulat

ion

7.7

33.9

10.5

4.5 5.6

0

15

30

45

60

75

90

FY 2011 FY 2012 FY 2013 FY 2014 FY 2015 FY 2016

Rate

per

10k

pov

erty

pop

ulat

ion

86.2

71.9 80.7 74.8

67.5 71.4

50.1 52.7

0

15

30

45

60

75

90

FY 2011 FY 2012 FY 2013 FY 2014 FY 2015 FY 2016

Rate

per

10k

pov

erty

pop

ulat

ion

Heroin and opioid treatment admissions vary by population area.

25

Source: Tennessee Department of Mental Health and Substance Abuse Services WITS, FY 2011-FY 2016 Notes: (1) TDMHSAS-funded substance abuse treatment admissions only include treatment admissions for Tennessee residents age 12 and older, below the 133% poverty line and have no insurance for which there was a bill. Up to three substances can be listed for each treatment admission. (2) Metro counties = most populated counties. (3) Suburban = centered on an urban cluster with a population >50,000. (4) small town = centered on an urban cluster with a population 10,000 - 50,000. (5) not part of an urban cluster. (6) Heroin admissions include any mention of heroin. (7) Opioid treatment admissions include any mention of opioids or methadone. (8) Injection drug use includes all drugs.

Opioid7 rates are highest in rural areas and

small towns

Injection drug use8 rates are now similar

across areas Heroin6 rates are

highest in urban areas

TDMHSAS treatment admissions1 (per 10K poverty population) by population area: FY 2011-FY 2016

2

3

4

5


Clay

Fentress Jackson Washington Campbell

Hawkins

DeKalb

Sullivan

TDMHSAS treatment admissions for heroin are urban, while opioids are rural.

26

TDMHSAS treatment admissions per 10K poverty population, FY 2015-FY 2016

Notes: (1) Rates are only shown for counties where the combined count during the time period was greater than 5. Rates based on two year averages. (2) Rates computed per 10K of the population of those 12 years and older, living in poverty. (3) Heroin admissions include any mention of heroin. (4) Opioid treatment admissions include any mention of opioids or methadone. Source: Tennessee Department of Mental Health and Substance Abuse Services WITS, 2015-2016

Admission per 10k

Shelby

Madison

Chester

Davidson

Hamilton

Knox

Admission per 10k


Opioids

Heroin

Treatment admissions for injection drug use are increasing.

E. Omohundro, PhD, 3/15/2017 Office of Research 27

2,210

4,101

1,737

2,412

384

1,339

245

1,263

0

1,000

2,000

3,000

4,000

FY 2011 FY 2012 FY 2013 FY 2014 FY 2015 FY 2016

Num

ber o

f adm

issi

ons

Number of TDMHSAS admissions by drug injected: FY 2011 - FY 2016

All drugs Opioids Methamphetamine Heroin

59% inject opioids

31% inject heroin

Of all injection drug admissions:

33% inject methamphetamine

Injection drug users in TDMHSAS treatment are concentrated in east Tennessee.

28

Source: Tennessee Department of Mental Health and Substance Abuse Services WITS, FY 2015-FY 2016 Notes: (1) Rates are only shown for counties where the combined count during the time period was greater than 5. Rates based on two year averages. (2) Rates computed per 10K of the population of those 12 years and older, living in poverty. (3) Opioid treatment admissions include any mention of opioids or methadone .

Admission per 10k

Grundy

Blount

DeKalb White

Van Buren

Hardin

Lewis

Fentress Washington Campbell

Hancock Clay

Morgan

Hamblen Greene

Fentress Washington

Campbell Hancock

Grundy

Blount

DeKalb

Admission per 10k


TDMHSAS treatment admissions per 10K poverty population, FY 2015-FY 2016

All injection drug users

Opioid injection drug users

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