Surveilling Non-Opioid Substance Use: Utilizing Multiple Data Sources in Marion County, Indiana

ObjectiveTo assess the prevalence of non-opioid substance use—including cocaine, methamphetamine and “spice”—within Marion County, Indiana and propose response recommendations utilizing a current opioid response plan.IntroductionCocaine, methamphetamine, and “spice” are addictive, non-opioid substances that negatively impact a person’s health through direct and indirect means. Direct health concerns of non-opioid substance use include anxiety, paranoia, seizure, heart attack, stroke, and potentially death while indirect health concerns include the acquisition of disease and infections, particularly sexually transmitted infections (STIs). Substance users experience an increased risk of acquiring STIs since they may exchange sex for substances, use substances within a social setting that may lead to sexual activity, or engage in risky sexual behavior as a result of impaired judgement associated with substance use. The current study evaluated the use of multiple data sources to monitor changes in the rate of cocaine, methamphetamine, and “spice” related emergency department visits as well as cocaine- and methamphetamine-related death rates, within Marion County, Indiana between 2013 and 2017.MethodsTwo data sources were used in this study. First, prevalence rates of non-opioid substance related emergency department (ED) visits were calculated using Marion County (IN) ED data from Electronic Surveillance System for the Early Notification of Community-Based Epidemics (ESSENCE) between 2013 and 2017. Second, cocaine and methamphetamine death rates were calculated using coroner toxicology data related to Marion County deaths between 2013 and 2017. Cocaine and methamphetamine deaths were defined as any death in which cocaine and methamphetamine was found in the toxicology results, respectively. All rates were calculated per 100,000 and age-adjusted to the 2000 U.S. Census using SAS Enterprise Guide v7.1.ResultsNon-opioid substance related ED visits have persistently risen between 2013 and 2017 (Figure 1). Methamphetamine and “spice” related ED visits exhibited similar prevalence patterns, increasing from 0.99 (0.72, 1.58) to 5.32 (4.67, 6.21) and 0.46 (0.28, 1.00) to 4.13 (3.57, 4.94) per 100,000, respectively, between 2013 and 2016. Cocaine-related ED visits consistently exhibited the highest prevalence rates, ranging from 3.72 (3.17, 4.44) to 23.56 (22.16, 25.11) per 100,000 in 2013 and 2016, respectively. In 2017, all non-opioid substance related ED visits drastically increased to 47.78 (45.79, 49.91), 48.48 (46.48, 50.67), and 42.08 (40.23, 44.13) per 100,000 for cocaine, methamphetamine, and “spice,” respectively. Further, we looked at cocaine- and methamphetamine-related death rates using coroner toxicology results. We found that between 2013 and 2017, the cocaine-related death rate nearly tripled, from 4.82 (4.20, 5.64) per 100,000 in 2013 to 13.01 (11.97, 14.23) per 100,000 in 2017 (Figure 2). Similarly, methamphetamine-related death rates increased from 1.31 (0.99, 1.92) per 100,000 in 2013 to 10.15 (9.25, 11.28) per 100,000 in 2017 (Figure 2). We did not calculate death rates of those who were found to have “spice” in their system at the time of death due to low prevalence.ConclusionsThe increase of non-opioid substance related ED visits in Marion County may indicate that non-opioid substance use—particularly cocaine, methamphetamine, and “spice”—may be an emerging public health issue in Marion County. This growing concern is further supported by the consistent increase in cocaine- and methamphetamine-related death rates. A limitation to our study is the inconsistent reporting of the substance in ED chief complaints and missing fields for discharge diagnoses and triage notes. As such, this inconsistency may have led to an underestimation of the prevalence rates of non-opioid substance related ED visits. The addition of triage notes and more reliable discharge diagnoses in 2017 ultimately culminated in a sharp increase in non-opioid substance related ED visits in 2017.Certain aspects of Marion County Public Health Department’s established opioid response plan may be used to address the growing concern of non-opioid substance use. These aspects include, but are not limited to, engaging community partners, creating a task force, establishing focus groups, and providing resources. While these aspects are critical to effectively respond to non-opioid substance use epidemics, establishing the various components prior to an outbreak enable communities to reduce the impact of such epidemics, if not prevent them from occurring. Additionally, it is important to incorporate participatory aspects into a non-opioid substance response plan such that community members are the driving force to provide context for the impact that non-opioid substance use is having on the community while also offering insight into which interventions would be most effective.

An Assessment of Overdose Surveillance at a Local Public Health Department

ObjectiveTo assess the data sources used to monitor overdose events in Marion County and improve community overdose surveillance.IntroductionMirroring public health response to infectious disease outbreaks, many public health departments are taking an outbreak management approach to respond to drug overdose surges 1-3. The Marion County Public Health Department (MCPHD) has developed an overdose response plan (ORP) integrating drug overdose surveillance and community stakeholder response strategies. Effective drug overdose surveillance requires accurate and reliable data streams. This work assessed data sources utilized for county overdose surveillance and provided recommendations to improve overdose surveillance.MethodsData sources utilized as of September 2018 for opioid overdose surveillance in Marion County were assessed on utilization history by epidemiologists. General recommendations to improve overdose surveillance were created based on the findings. The three primary sources were emergency department data, ambulance run data, and death certificate data. Secondary sources included Indiana Poison Center (IPC) and toxicology data. General recommendations were generated based on challenges/solutions encountered and good practices observed from other health departments 4,5.ResultsThe assessment of data sources and utilization showed variation of data entry at the hospital level, limited identifiers in some cases, and varying timeliness ranges which may limit combined use of many data sources. The emergency department data source showed particular variation in data entry, limited unique identifier information), and no incident location information which impedes geographical surveillance. Periodic data checks by the ambulance service data holder appears to drastically increase data quality. Intermittent data feed drops from specific emergency departments also interfered with effective surveillance. Recommendations were generated based on lessons learned during successful partnerships with Indianapolis Emergency Medical Services, IPC, and emergency departments and challenges encountered during overdose surveillance work (Figure 1).In application of the strategy, the MCPHD is interested in linking data and looking for other ways to improve our overdose response to get a fuller picture of what is happening with overdoses, so we applied the steps in figure one to find areas of improvement. We found that limited identifiers and incomplete fields are our biggest challenge to linking datasets, so to combat these gaps we identified sources that have the necessary fields of interest and have been working with others to improve the data quality. Additionally, data sources will be evaluated on experiences with three categories: completeness in data fields, timeliness of data delivery, and consistency of data feed. Data quality measures were developed for completeness by fields present per record, timeliness by lag time from time added to time of event, and consistency by record counts per facility over time. We also recognized that meeting with partners is necessary to share how we are using the data and additional datasets that we might use in the future. Additionally we have been meeting with academic researchers so that we can expand our analyses to identify other issues related to overdoses. Finally, in order to make a difference in Marion County we are applying our findings to our outreach and interventions to hopefully prevent more overdoses and deaths.Future plans include data partnerships include police drug arrest data, fire department naloxone administration data, prescription drug monitoring data, Medicaid claims data, and health information exchange overdose data. Future research partnerships will consider a solutions based framework 6.ConclusionsThe results of our work demonstrate the value in surveillance assessment to summarize limitations of the many data sources utilized at a local level to conduct overdose surveillance. Our evaluation approach provides a path to improve and fill in surveillance gaps with new processes. Other health departments interested in optimizing overdose surveillance may seek a similar evaluation approach. Periodic data linkages have not been implemented which presents an opportunity to glean valuable insights on longitudinal patterns of drug use in the population. Future collaboration with researchers presents an opportunity to improve MCPHD ORP, Safe Syringe Access and Support Program, and Substance Use Outreach Services interventions.References[1] Moore K, Boulet M, Lew J, Papadomanolakis-Pakis N. A public health outbreak management framework applied to surges in opioid overdoses. Journal of opioid management. 2017;13(5):273-81.[2] Rudd RA. Increases in drug and opioid-involved overdose deaths—United States, 2010–2015. MMWR. Morbidity and mortality weekly report. 2016;65.[3] Rowe C, Wheeler E, Jones TS, Yeh C, Coffin PO. Community-Based Response to Fentanyl Overdose Outbreak, San Francisco, 2015. Journal of Urban Health. 2018 May 3:1-6.[4] Chen H, Hailey D, Wang N, Yu P. A review of data quality assessment methods for public health information systems. International journal of environmental research and public health. 2014 May 14;11(5):5170-207.[5] Massachusetts. Department of Public Health. An Assessment of Opioid-Related Deaths in Massachusetts (2013-2014). Massachusetts Department of Public Health; 2016.[6] Wiehe SE, Rosenman MB, Chartash D, Lipscomb ER, Nelson TL, Magee LA, Fortenberry JD, Aalsma MC. A Solutions-Based Approach to Building Data-Sharing Partnerships. eGEMs. 2018;6(1)