# Presentation: 120327

## Methadone Mortality – A Reassessment       Decedents in Rural Virginia 

- Martha J Wunsch MD FASAM
- Kent  Nakamoto PhD

## *Opioids as a direct or contributing cause of death

- *Opioids as a direct or contributing cause of death

| Year  | Drug Deaths | Opioid Related Deaths* | Oxycodone | Methadone  | Fentanyl  | Hydrocodone | MSO4 |
| --- | --- | --- | --- | --- | --- | --- | --- |
| 1997 | 67 | ? | 1 | 4 | 0 | 6 | 12 |
| 1998 | 69 | 8 | 3 |  6 |  0 | 12 | 7 |
| 1999 | 84 | 25 | 18 | 12 |  0 | 8 | 11 |
| 2000 | 101 | 36 | 19 |  22 |  1 | 10 | 17 |
| 2001 | 164 | 95 | 41 |  49 | 9 | 34 | 13 |
| 2002 | 185 | 101 | 26 | 62 | 12 | 42 | 21 |
| 2003 | 223 | 157 | 44 | 88  | 21 | 47 | 15 |
| 2004 | 243 | ? | 37 | 69 | 22 | 47 | 36 |
| 2005 | 210 | ? | 36 | 70 | 14 | 47 | 31 |

**Notes:**
WE GOTTA PROBLEM!

Polysubstance deaths 

Lack of “traditional street drugs” such as heroin and cocaine
Prescription drugs identified: opiates, benzodiazepines, antidepressants 
Not just methadone—Hydrocodone, Oxycodone
Scene investigations: Drug trafficking, diversion, prescription fraud

## “Opioid Mortality in Southwestern Virginia” 

- M Wunsch MD,
- W Massello MD, G Behonick PhD,
- K Nakamoto PhD

- *National Institute of Drug Abuse RO3 DA019047-01A1

**Notes:**
Multidisciplinary: ME, Toxicologist, Addiction Medicine specialists

## Overall Goal

- Characterize individuals who die from prescription drugs in a rural area of Virginia
- Who is dying?
- From what drugs?
- Is this “traditional” drug abuse?

## Geographic AreaOpioid Deaths in Rural Virginia

- Wise + Norton

- Russell County

- Tazewell County

- Washington County + Bristol

- Henry County + Martinsville

- Pulaski County + Radford

- Montgomery    County

- Roanoke/ Roanoke County + Salem

**Notes:**
Highlights of this region 7 HOURS FROM DC....got to NYC
34 counties, almost entirely rural—only one city with pop. 100,000. Total population of region 1.5 million.
Remote and mountainous--Appalachia
Serious economic decline—traditional industries textiles and forest products almost all lost to offshoring. Mining recent resurgence but unemployment in the region is still more than double that in Northern VA.

## Methods

-  893 “Drug Death” OCME Files 1997-2003
- Autopsy Results
- Death Certificates
- Death Scene Investigations
- Police Reports
- Toxicology Reports
- Physician Notes
- Hospital Records ( ER, Inpatient, Psych)

**Notes:**
Data Base SPSS designed for this study allows importation for stat evaluation

## Drug Deaths....Opioid Deaths

**Notes:**
Increase due to opioid deaths (parallel lines)
Serious Problem: Death Rate depending on age group 6 to 10 times national average.

## Opioids Identified on Toxicology

| Age | Under 20 | 20-34 | 35-54 | 55 or Over |  |
| --- | --- | --- | --- | --- | --- |
| N | 23 | 140 | 293 | 20 |  |
| Heroin | 1 | 7 | 13 | 0 | p>.10 |
| Methadone | 18 | 83 | 142 | 7 | p<.01 |
| Oxycodone or Schedule II1 | 4 | 71 | 145 | 10 | p<.05 |
| Hydrocodone or Codeine2 | 7 | 56 | 133 | 9 | p>.10 |
| Schedule IV or other3 | 4 | 30 | 81 | 8 | p>.10 |
| 1Fentanyl, Hydromorphone, Morphine, Oxymorphone
2Schedule II or III depending on preparation
3Propoxyphene, Tramadol (not scheduled) |  |  |  |  |  |

**Notes:**
MOST prevalent drug involved in these deaths was methadone

Additionallly, oxycodone, hydrocodone frequently encountered in these cases.

## Case Definition: Methadone Deaths

- 893 Drug Deaths (1997-2003)
- 643 NO methadone identified by toxicology
- 6 Classified as “methadone as COD”
- 250 methadone identified by toxicology
- 243 Classified as methadone as direct or contributing COD
- 243 cases *where methadone was a direct or contributing cause of death AND toxicology was positive *

## 243 Methadone Cases

**Gender**
-  75.2% Male ; 24.8% Female
**Race **
- 98% White ; 1.2% African American; .4 % Asian
**Marital Status**
- 36.8% married;12% cohabitating
- 14% divorced
- 28.8% single
**Education:** 34% <High School; 46% HS grads

**Notes:**

Gender  all DD: 58% Male; 42% Female (p<.001)
Race: more AA  in DD: 92% White; 7.5% African American, .5% Native American(p<.01)

Marital Status: All DD more divorced, mtd more cohabitating (p <.01)

Education n.s.
34% < High School
46% HS graduate
14% Trade/Associates degree
2 % College or more education
4% unknown

## Age Distribution of Cases

**Notes:**
The Centers for Disease Control identified 11 states in which undetermined and unintended poisoning deaths increased by an average of 145% between 1990-2001.6 While the number of heroin poisonings increased by 12.4% from 1999 to 2002, the number of opioid analgesic poisonings in the US increased by 91.2%. 

The 2003 New Dawn Report reported increased opioid-related drug misuse deaths in Maine, New Hampshire, Vermont, Maryland, Utah, and New Mexico involving predominantly the prescription medications oxycodone, hydrocodone, and methadone. 5 CDC New Mexico, Vermont, Utah, Maine, New Hampshire 35-54 y/o, Maryland younger

## Manner of DeathMethadone Cases

| Type of Death | Male | Female |
| --- | --- | --- |
| Accident | 88.8%* | 80.6%* |
| Suicide | 8%* | 19.4%* |
| Unknown | 1.6% | 0 |

**p<.001**

**Notes:**
TOTAL SAMPLE
Females suicide 42.5, accident 52.6
Males suicide 23.3, accident 73.5

## Prescriptions in Decedent Name

- A decedent was noted to have a prescription for a medication if a bottle in their name was found at death scene, noted as prescribed in a medical record, or listed in death scene pharmacy log
- Any Opioid Prescription?
- 45.2% of cases had a Rx for an Opioid
- Any Methadone Rx?
- 23.6% of cases had a Rx for methadone

**Notes:**
OF THOSE WITH OPIOID RX HALF HAD ONE FOR METHADONE

Non methadone deaths: 1% had a rx for mtd
Prescription Present: Three indicators were used to identify that the decedents had been prescribed an opioid medications: 1) Presence at the death scene of a labeled prescription bottle in the name of the decedent from field medical examiner reports 2) Record from an attending physician or hospital note indicating the decedent was prescribed an opioid medication 3) Death investigation pharmacy logs indicating an opioid prescription in the name of the decedent.

## Source of methadone in 68 cases (2004)

**Notes:**
Verifies what we found—1/4 with rx from doc
AND because 13% had been in MMT....

WE are probably underestimating the # decedents who are prescribed methadone for medical problem—mmt or pain.

## Medical Diagnosis

- Chronic Pain 40%
- 55 % have an antidepressant on toxicology
- 55 % have a benzodiazepine on toxicology
- Anxiety Disorder 19%
- 50% have an antidepressant on toxicology
- 46% have a benzodiazepine on toxicology
- Depression 40%
- 60% have an antidepressant on toxicology
- 56% have a benzodiazepine on toxicology

**Notes:**
Scene Investigator
ME note on autopsy
Note in medical chart

 BZD higher

## Toxicology Results

- Opioids
- 68% had only methadone present
- 24% had methadone AND another opioid present
- 8% had methadone AND 2 or more opioids present

## Implications

- Traditional View (NSDUH) This is an epidemic of young people using prescription drugs non-medically to “get high”
- Western Virginia (and probably other rural areas):
- Highest accidental mortality among adults 35-54.
- Many hold a prescription for methadone or opioid.
- Medical history consistent with prescription.
***Perhaps these deaths are due to misuse of prescribed opioids including methadone.***
*A different problem calling for different strategies.*

**Notes:**
Educating providers and patients