Predicting accidental drug overdose as the cause of fatality in near real-time using the Suspected Potential Overdose Tracker (SPOT): public health implications.

BACKGROUND: Effective responses to the worsening drug overdose epidemic require accurate and timely drug overdose surveillance data. The objectives of this paper are to describe the development, functionality, and accuracy of the Suspected Potential Overdose Tracker (SPOT) for predicting accidental drug overdose as the cause and manner of death in near real-time, and public health implications of adopting the tool. METHODS: SPOT was developed to rapidly identify overdose deaths through a simple and duplicable process using data collected by death investigators. The tool assigns each death a ranking of 1 through 3 based on the likelihood of it being an unintentional drug overdose, with 1 representing the highest likelihood that the death will be confirmed as an unintentional drug overdose and 3 representing the lowest. We measured the accuracy of the tool for predicting overdose deaths by comparing potential overdose deaths in New York City from 2018-2020 that were identified using SPOT to finalized death certificates. We also calculated the proportion of death certificate-confirmed overdoses that were missed by the SPOT tool and the proportion of type 1 errors. RESULTS: SPOT captured up to 77% of unintentional drug overdose deaths using data collected within 72 h of fatality. The tool predicted unintentional drug overdose from 2018 to 2020 with 93-97% accuracy for cases assigned a ranking of 1, 87-91% accuracy for cases assigned a ranking of 2, and 62-73% accuracy for cases assigned a ranking of 3. Among all unintentional overdose deaths in 2018, 2019, and 2020, 21%, 28%, and 33% were missed by the SPOT tool, respectively. During this timeframe, the proportion of type 1 errors ranged from 15%-23%. CONCLUSIONS: SPOT may be used by health departments, epidemiologists, public health programs, and others to monitor overdose fatalities before death certificate data becomes available. Improved monitoring of overdose fatalities allows for rapid data-driven decision making, identification of gaps in public health and public safety overdose response, and evaluation and response to overdose prevention interventions, programs, and policies.

Characterizing opioid overdose hotspots for place-based overdose prevention and treatment interventions: A geo-spatial analysis of Rhode Island, USA.

OBJECTIVE: Examine differences in neighborhood characteristics and services between overdose hotspot and non-hotspot neighborhoods and identify neighborhood-level population factors associated with increased overdose incidence. METHODS: We conducted a population-based retrospective analysis of Rhode Island, USA residents who had a fatal or non-fatal overdose from 2016 to 2020 using an environmental scan and data from Rhode Island emergency medical services, State Unintentional Drug Overdose Reporting System, and the American Community Survey. We conducted a spatial scan via SaTScan to identify non-fatal and fatal overdose hotspots and compared the characteristics of hotspot and non-hotspot neighborhoods. We identified associations between census block group-level characteristics using a Besag-York-Mollié model specification with a conditional autoregressive spatial random effect. RESULTS: We identified 7 non-fatal and 3 fatal overdose hotspots in Rhode Island during the study period. Hotspot neighborhoods had higher proportions of Black and Latino/a residents, renter-occupied housing, vacant housing, unemployment, and cost-burdened households. A higher proportion of hotspot neighborhoods had a religious organization, a health center, or a police station. Non-fatal overdose risk increased in a dose responsive manner with increasing proportions of residents living in poverty. There was increased relative risk of non-fatal and fatal overdoses in neighborhoods with crowded housing above the mean (RR 1.19 [95 % CI 1.05, 1.34]; RR 1.21 [95 % CI 1.18, 1.38], respectively). CONCLUSION: Neighborhoods with increased prevalence of housing instability and poverty are at highest risk of overdose. The high availability of social services in overdose hotspots presents an opportunity to work with established organizations to prevent overdose deaths.

Effects of States' Methods for Estimating Nonfatal Overdose, United States, 2021.

OBJECTIVE: Previous nonfatal overdose is a key risk factor for drug overdose death; however, current nonfatal overdose surveillance is limited to people who receive medical attention. We identified states that tracked nonfatal overdoses treated in prehospital and hospital care settings, assessed the effects of different surveillance methods on the magnitude of nonfatal overdose estimates, and estimated states' nonfatal-to-fatal overdose ratio. METHODS: Two analysts independently reviewed state websites to characterize states' methods of capturing nonfatal overdose events from December 2022 through February 2023. We collected information on surveillance methods in 5 states that met the inclusion criteria, including data source, measure specification, drug(s) involved, and whether states performed deduplication or published mutually exclusive measure specifications to capture unique events across care settings. We calculated nonfatal-to-fatal overdose ratios to assess the effects of different data sources on estimates of nonfatal overdoses. RESULTS: Illinois, Maine, North Carolina, and West Virginia used syndromic surveillance data and New Jersey used hospital discharge data to track nonfatal overdose-related emergency department visits. Illinois and West Virginia tracked nonfatal overdose-related encounters with emergency medical services. Other states tracked opioid overdoses reversed following naloxone administration by emergency medical services, law enforcement, and community members. Maine, New Jersey, and West Virginia published nonfatal overdose information by using mutually exclusive measure specifications; the number of nonfatal overdoses per fatal overdose in these states ranged from approximately 5:1 to 14:1. PRACTICE IMPLICATIONS: Establishing a standard framework to combine data from existing national surveillance systems in prehospital and hospital care settings can improve nonfatal overdose estimates and enable comparisons between jurisdictions to help decision makers identify areas most in need of essential services.

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.

Redefining and categorizing emergency medical service opioid-related incidents in Massachusetts.

AIMS: To create a novel emergency medical service (EMS) opioid-related incident (ORI) tiering framework to describe more accurately the opioid epidemic in Massachusetts. By classifying the data, we could more accurately detail differing trends among the new categories. DESIGN: Free-text fields of Massachusetts EMS reports, from 2013 through 2020, were analyzed to identify ORIs and then categorized into a five-tier severity cascade based on symptom presentation: 'dead on arrival,' 'acute overdose,' 'intoxication,' 'withdrawal' and 'other ORI.' As a validation of the new classification, an emergency medical technician, paramedic and emergency medical physician reviewed clinical reports and assigned a severity category to 100 randomly selected cases. The algorithm then assessed the same 100 cases to determine if it could accurately identify the severity category for each case. FINDINGS: Validation of the algorithm by clinical review indicated a substantial level of agreement between the algorithm and the reviewers. Over half of all ORIs were acute overdose (55%), 21% were intoxication, 20% were other ORI, 3% were withdrawal, and 1% were dead on arrival. Overall ORIs decreased in 2020, but the number of 'dead on arrival' increased 32% from 2019. Administration of naloxone also differed between the categories, with 95% of acute overdose and 29% of intoxication receiving naloxone. CONCLUSIONS: This novel categorization of emergency medical service opioid-related incidents in Massachusetts, United States, reveals new trend details and strains on the emergency medical service system. Using these categories also improves dataset linkage within the state and interstate rate comparisons.

Charting the fourth wave: Geographic, temporal, race/ethnicity and demographic trends in polysubstance fentanyl overdose deaths in the United States, 2010-2021.

AIMS: To characterize polysubstance death in the United States during the transition to the fourth wave of the drug overdose crisis. To characterize co-involved substances in fatal overdose involving synthetic opioids (mainly illicitly manufactured fentanyl analogues) by year, state, and intersectional sociodemographic groups. DESIGN: Population-based study of national death records. SETTING: United States. PARTICIPANTS/CASES: All people who died from drug overdose in the United States between 2010 and 2021. MEASUREMENTS: Percentage of all fatal overdose involving fentanyls, stimulants, and other drugs. Most commonly co-involved substances in fentanyl overdose by state and year. Percentage of fatal fentanyl overdose co-involving stimulants by state and year. Percentage of fatal fentanyl overdose co-involving stimulants by intersectional region, race/ethnicity, age, and sex. FINDINGS: The percent of US overdose deaths involving both fentanyl and stimulants increased from 0.6% (n = 235) in 2010 to 32.3% (34 429) in 2021, with the sharpest rise starting in 2015. In 2010, fentanyl was most commonly found alongside prescription opioids, benzodiazepines, and alcohol. In the Northeast this shifted to heroin-fentanyl co-involvement in the mid-2010s, and nearly universally to cocaine-fentanyl co-involvement by 2021. Universally in the West, and in the majority of states in the South and Midwest, methamphetamine-fentanyl co-involvement predominated by 2021. The proportion of stimulant involvement in fentanyl-involved overdose deaths rose in virtually every state 2015-2021. Intersectional group analysis reveals particularly high rates for older Black and African American individuals living in the West. CONCLUSIONS: By 2021 stimulants were the most common drug class found in fentanyl-involved overdoses in every state in the US. The rise of deaths involving cocaine and methamphetamine must be understood in the context of a drug market dominated by illicit fentanyls, which have made polysubstance use more sought-after and commonplace. The widespread concurrent use of fentanyl and stimulants, as well as other polysubstance formulations, presents novel health risks and public health challenges.

Methodological Complexities in Quantifying Rates of Fatal Opioid-Related Overdose.

PURPOSE OF REVIEW: Effective responses to the US opioid overdose epidemic rely on accurate and timely drug overdose mortality data, which are generated from medicolegal death investigations (MDI) and certifications of overdose deaths. We identify nuances of MDI and certification of overdose deaths that can influence drug overdose mortality surveillance, as well as recent research, recommendations, and epidemiological tools for improved identification and quantification of specific drug involvement in overdose mortality. RECENT FINDINGS: Death certificates are the foundation of drug overdose mortality surveillance. Accordingly, counts and rates of specific drug involvement in overdose deaths are only as accurate as the drug listed on death certificates. Variation in systematic approaches or jurisdictional office policy in drug overdose death certification can lead to bias in mortality rate calculations. Recent research has examined statistical adjustments to improve underreported opioid involvement in overdose deaths. New cause-of-death natural language text analysis tools improve quantification of specific opioid overdose mortality rates. Enhanced opioid overdose surveillance, which combines death certificate data with other MDI-generated data, has the potential to improve understanding of factors and circumstances of opioid overdose mortality. SUMMARY: The opioid overdose crisis has brought into focus some of the limitations of US MDI systems for drug overdose surveillance and has given rise to a sense of urgency regarding the pressing need for improvements in our MDI data for public health action and research. Epidemiologists can stimulate positive changes in MDI data quality by demonstrating the critical role of data in guiding public health and safety decisions and addressing the challenges of accurate and timely overdose mortality measures with stakeholders. Education, training, and resources specific to drug overdose surveillance and analysis will be essential as the nation's overdose crisis continues to evolve.