Office Of The Chief Medical Examiner Research Articles

Innovations in Fatality Management During the COVID-19 Pandemic.

Innovations in Fatality Management During the COVID-19 Pandemic.

Mortality Among People Experiencing Homelessness in San Francisco During the COVID-19 Pandemic

There has been recent media attention on the risk of excess mortality among homeless individuals during the COVID-19 pandemic, yet data on these deaths are limited. To quantify and describe deaths among people experiencing homelessness in San Francisco during the COVID-19 pandemic and to compare the characteristics of these deaths with those in prior years. A cross-sectional study tracking mortality among people experiencing homelessness from 2016 to 2021 in San Francisco, California. All deceased individuals who were homeless in San Francisco at the time of death and whose deaths were processed by the San Francisco Office of the Chief Medical Examiner were included. Data analysis was performed from August to October 2021. Homelessness, based on homeless living status in an administrative database. Descriptive statistics were used to understand annual trends in demographic characteristics, cause and manner of death (based on autopsy), substances present in toxicology reports, geographic distribution of deaths, and use of health and social services prior to death. Total estimated numbers of people experiencing homelessness in San Francisco were assessed through semiannual point-in-time counts. The 2021 point-in-time count was postponed owing to the COVID-19 pandemic. In San Francisco, there were 331 deaths among people experiencing homelessness in the first year of the COVID-19 pandemic (from March 17, 2020, to March 16, 2021). This number was more than double any number in previous years (eg, 128 deaths in 2016, 128 deaths in 2017, 135 deaths in 2018, and 147 deaths in 2019). Most individuals who died were male (268 of 331 [81%]). Acute drug toxicity was the most common cause of death in each year, followed by traumatic injury. COVID-19 was not listed as the primary cause of any deaths. The proportion of deaths involving fentanyl increased each year (present in 52% of toxicology reports in 2019 and 68% during the pandemic). Fewer decedents had contacts with health services in the year prior to their death during the pandemic than in prior years (13% used substance use disorder services compared with 20% in 2019). In this cross-sectional study, the number of deaths among people experiencing homelessness in San Francisco increased markedly during the first year of the COVID-19 pandemic. These findings may guide future interventions to reduce mortality among individuals experiencing homelessness.

Trends in fatal occupational injuries in Latino/a workers relative to other groups, North Carolina 2000-2017.

Latino/a workers may experience higher fatal occupational injury rates than non-Latino/a workers. In North Carolina, the Latino/a population more than doubled between 2000 and 2017. We examined fatal occupational injuries among Latino/a and non-Latino/a workers in North Carolina over this period. Information on fatal occupational injuries was abstracted from records of the North Carolina Office of the Chief Medical Examiner and the death certificate records held by the North Carolina Office of Vital Records. Estimates of the working population were derived from the decennial census and American Community Survey. Estimates of annual rates of fatal occupational injury for the period January 1, 2000 to December 31, 2017 were derived for Latino/a workers and compared to Black and White workers not identified as Latino/a. Over the study period, 1,783 fatal occupational injuries were identified among non-Latino/a workers and 259 fatal occupational injuries among Latino/a workers in North Carolina. The majority of fatal occupational injuries among Latino/a workers occurred among males employed in construction and agriculture. While the fatal occupational injury rate among Latino/a workers declined over the study period, the rate among Latino/a workers was higher than among non-Latino/a White and Black workers; moreover, fatal occupational injury rates for Latino/a workers trended upwards during the most recent years of the study period. Latino/a workers in North Carolina have the highest fatal occupational injury rate of any race/ethnicity group.

Epidemiology and autopsy findings of 500 drowning deaths

IntroductionDrowning is a significant public health problem worldwide and the WHO reported that drowning is the world’s third leading unintentional injury death. Nevertheless, there is still uncertainty regarding the estimate of local and global drowning deaths. In addition, the postmortem diagnosis of drowning is challenging and the physiological mechanisms of death by drowning are complex and not very well understood. PurposeTo analyze a large series of bodies retrieved from the water in Connecticut (U.S.) in order to compare epidemiologic and toxicological data with those of the literature, as well as to examine the weights of the lungs and brains in drowning deaths. Material and methodWe conducted a descriptive, retrospective, population-based analysis of all bodies retrieved from the water and subjected to a forensic autopsy at the Office of the Chief Medical Examiner in Connecticut (2008–2020, n = 500). Variables collected were sex, age, date of death, location of drowning, season, type of water, cause of death, manner of death, circumstances of death, signs of decomposition, BMI, brain weight, lung weight, presence of pulmonary edema, stomach contents, and toxicological analysis. ResultsThe death rates of drownings in Connecticut ranges from 0.75 to 1.28/100,000/year. They occurred predominantly in males (73.4%) and most were accidents (75.6%), though this gender difference diminishes in suicides (55.4% of males). Sex distribution is also different in bathtub drownings, where women drown more frequently (67.3%). Weights of the brains (p = 0.013) and lungs (p < 0.001) were higher in saltwater drownings. ConclusionsDrowning is more frequently an accident involving men, except for suicides where there is only a slight difference among sex. Heavy lungs and cerebral edema continue to be identified in numerous drowning deaths. These anatomic findings, however, must still be interpreted in the context of the entire case investigation. Weights of the brains and lungs are higher in salt water, although these organs’ weights are mostly dependent on other variables such as BMI and decomposition.

Improvements in Toxicology Testing to Identify Fentanyl Analogs and Other Novel Synthetic Opioids in Fatal Drug Overdoses, Connecticut, January 2016–June 2019

Drug overdose deaths in Connecticut increasingly involve a growing number of fentanyl analogs and other novel nonfentanyl synthetic opioids (ie, novel synthetics). Current postmortem toxicology testing methods often lack the sophistication needed to detect these compounds. We examined how improved toxicology testing of fatal drug overdoses can determine the prevalence and rapidly evolving trends of novel synthetics. From 2016 to June 2019, the Connecticut Office of the Chief Medical Examiner increased its scope of toxicology testing of suspected drug overdose deaths in Connecticut from basic to enhanced toxicology testing to detect novel synthetics. The toxicology laboratory also expanded its testing panels during this time. We analyzed toxicology results to identify and quantify the involvement of novel synthetics over time. From 2016 to June 2019, 3204 drug overdose deaths received enhanced toxicology testing; novel synthetics were detected in 174 (5.4%) instances. Ten different novel synthetics were detected with 205 total occurrences. Of 174 overdose deaths with a novel synthetic detected, most had 1 (n = 146, 83.9%) or 2 (n = 26, 14.9%) novel synthetics detected, with a maximum of 4 novel synthetics detected. Para-fluorobutyrylfentanyl/FIBF, furanylfentanyl, and U-47700 were most identified overall, but specific novel synthetics came in and out of prominence during the study period, and the variety of novel synthetics detected changed from year to year. Enhanced toxicology testing for drug overdose deaths is effective in detecting novel synthetics that are not identified through basic toxicology testing. Identifying emerging novel synthetics allows for a timely and focused response to potential drug outbreaks and illustrates the changing drug market.

Buprenorphine-Related Deaths in North Carolina from 2010 to 2018.

Buprenorphine (BUP) is a commonly prescribed medication for the treatment of opioid use disorder (OUD). As prescriptions increase in North Carolina, BUP is more frequently encountered statewide in routine postmortem casework. Between 2010 and 2018, there were 131 select cases investigated by the Office of the Chief Medical Examiner where BUP was detected in peripheral blood and considered a primary cause of death (COD), with no other opioids present and no other non-opioid substances found in the lethal range. The decedents ranged in age from 14 to 64 years, with 67% male. The mean/median peripheral blood concentrations were 4.1/2.1 ng/mL for BUP and 7.8/3.4 ng/mL for its metabolite, norbuprenorphine. These postmortem blood concentrations overlap antemortem therapeutic concentrations in plasma reported in the literature for opioid-dependent subjects receiving sublingual maintenance therapy. The pathologist considered scene findings, prescription history, autopsy findings, toxicological analysis and decedent behavior prior to death to conclude a drug-related COD. Many of the deaths were complicated by the presence of other central nervous system depressants along with contributory underlying cardiovascular and respiratory disease. The three most prevalent additive substances were alprazolam, ethanol and gabapentin, found in 67, 36 and 32 cases out of 131, respectively. Interpreting BUP involvement in a death is complex, and instances may be underestimated in epidemiological data because of the lack of a defined toxic or lethal range in postmortem blood along with its good safety profile. As expansion of access to OUD treatment becomes a priority, awareness of the challenges of postmortem interpretation is needed as increased use and diversion of BUP are inevitable.

Accidental Deaths Involving Trees: Professional and Nonprofessional Woodcutting and Tree Failures With Autopsy Findings.

We examined all deaths in Connecticut involving tree mishaps (struck by a tree/tree limb, injuries associated with tree removal operations). Records of the Connecticut Office of the Chief Medical Examiner including autopsy, toxicology, and investigators' reports of deaths from 2004 to 2019 were reviewed. All underwent autopsy examination.There were 64 fatalities, with ages ranging from 4 to 90 years (mean, 50 years). The causes of death involved the following: 56 blunt injury (primary site: 25 head, 13 multiple locations, 11 torso, and 7 neck), 5 traumatic asphyxia, 2 electrocution, and 1 chainsaw injury. Deaths were classified into 3 groups: 21 nonprofessional woodcutters, 19 professional woodcutters, and 24 tree failures. Among all woodcutters (100% men), impact by a falling tree/limb (78%) was the most common fatal event, and the most common lethal injury site was the head (45%). For tree failures, 58% involved storm/high-wind events, whereas 42% were spontaneous. Of the tree failure events, 58% involved motor vehicles, with most (86%) occurring while driving. Ethanol was detected in 6 decedents with blood concentrations ranging from 0.02 to 0.19 gm%, of which 4 were nonprofessional and 2 were professional woodcutters. There were some seasonal differences among the 3 groups.Overall, fatalities of nonprofessional woodcutters, compared with professionals, were more likely to involve an older man (58 vs 40 years), working alone (67% vs 11%), and under the influence of ethanol (19% vs 11%) in late summer-autumn who dies of blunt head trauma from a falling tree or tree limb. Aggressive tree control management along highways has been used to attempt to decrease storm-related fatalities.

Experimental Formation of Marine Abrasion on Bone and the Forensic Postmortem Submergence Interval

Human skeletal remains are frequently recovered from marine environments, where they have undergone months or years of immersion, and decomposition stage is no longer a possible method from which to estimate the postmortem submergence interval (PMSI). Over these longer PMSIs, a common taphonomic alteration that forms is the wearing and rounding of surfaces from marine abrasion, caused by repeated agitation in sediment or against rocks. Little is known about the timing of these changes and how to measure or score the degree of alteration. In a laboratory setting, multiple dry, defleshed bones of white-tailed deer (Odocoileus virginianus) were agitated in saltwater for varying intervals with abrasive sediment (1, 2, 4, 6, 8, and 10 days) and with rocks (5 and 12 days) using a laboratory tumbling device. These were compared to human remains cases from the Office of the Chief Medical Examiner, Boston, MA that had been in the Atlantic Ocean for known intervals. A five-stage (0–4) marine abrasion scoring system was devised for the taphonomic analysis of forensic cases from marine environments to allow for direct comparison among cases. A high degree of correlation between abrasion stage and known PMSI was detected.

Pediatric opioid fatalities: What can we learn for prevention?

The aim of this study was to highlight 19 cases investigated by the North Carolina Office of the Chief Medical Examiner over the last 12years involving accidental or undetermined manner of death opioid ingestions leading to fatalities in young children. These pediatric ingestions have closely mirrored the opioid epidemic in adults transitioning from prescription medications to illicit drugs including fentanyl and fentanyl analogues. Unlike a typical adult ingestion for purposes of self-harm or pleasure, poisonings in toddlers and infants are usually the result of curiosity, exploration, a decreased sense of danger, or imitation of adult or older sibling behavior. Eleven of the decedents were between the ages of 8 and 24months. Among the cases were 12 prescription opioid exposure deaths and 7 illicit drug poisonings. A majority of the decedents were found unresponsive in an unkept home and/or in unsafe sleeping spaces with easy access to drugs or drug materials, which stresses the importance of safe pediatric sleeping conditions. After a complete pathological investigation, several of the cases had physical or scene evidence demonstrating that foil, plastic, or paper small enough to be ingested can contain enough potent opioid to cause death. Details from the toxicological investigation are included for each case to provide postmortem whole blood drug concentrations for forensic practitioners. Accidental pediatric poisonings are preventable. Risk reduction through improving awareness and education of the dangers of opioids is a key factor in mitigating these tragedies.

Trends in substances involved in polysubstance overdose fatalities in Maryland, USA 2003–2019

BackgroundThe substances driving the overdose epidemic in the United States have changed over time. Since 2013, fentanyl-analogues have become the primary opioids driving the epidemic. Recently, polysubstance related deaths have come to the forefront of the epidemic. Therefore, we explored trends in polysubstance involvement in overdose fatalities in Maryland between 2003 and 2019. MethodsWe used records for the Maryland Office of the Chief Medical Examiner between 2003 and 2019. First, we assessed trends in the number of drugs (1, 2, 3+) involved in overdose fatalities over time. Then, we assessed linear and quadratic trends in nine substance categories using logistic regression. ResultsOvertime, the proportion of overdose deaths involving one (ß=−0.28, p < 0.001) or two (ß=−0.14, p < 0.001) drugs decreased, while deaths involving three or more drugs increased (ß = 0.31, p < 0.001). The involvement of most drugs decreased over the study period. Only cocaine (linear ß=−0.08, p < 0.001; quadratic ß = 0.29, p < 0.001) and fentanyl (linear ß = 1.67, p < 0.001; quadratic ß = 0.75, p < 0.0001) showed significant increases over time. Post hoc analyses showed that cocaine involvement only increased in the presence of fentanyl (linear ß = 1.41, p < 0.001; quadratic ß = 0.70, p < 0.001) and decreased when fentanyl was not present (linear ß=−0.81, p < 0.001; quadratic ß=−0.31, p < 0.001). ConclusionsPolysubstance involvement in overdose fatalities has become more common over time in Maryland. Most individual substances became less common over time, while cocaine and fentanyl involvement increased. Unintentional fentanyl consumption through contaminated cocaine may be an increasingly important driver of deaths in Maryland, indicating the importance of implementing widespread harm reduction programs, especially drug checking.

Custodial deaths seen in the Office of the Chief Medical Examiner, Lagos, Nigeria: An 11-year autopsy study.

Deaths in custody are a matter of global concern. However, such information is often missing in developing countries. This study aimed to examine retrospectively the profile, cause and manner of deaths amongst cases of custodial deaths in Lagos State, Nigeria. An 11-year study (June 2008-June 2019) was done of all autopsy cases of custodial deaths in the Office of the Chief Medical Examiner. Variables including age, sex, offence, place of death, duration in custody prior to death and cause and manner of death were extracted from the records. Results were analysed using frequencies and percentages. Out of 9894 autopsies over the study period, 45 custodial deaths were identified. Males and females constituted 84.4% and 15.6%, respectively (M:F = 5.4:1). Ages ranged from 20 to 64 years, with a mean age of 37 ± 11.0 years. These deaths were most common in the third decade. Armed robbery and financial crime were the two leading reasons for arrest, while most deaths occurred within 24 hours of arrival in custody. The two leading causes of death were acute cardiac failure from hypertensive heart disease and cranio-cerebral injury from blunt-force trauma. Deaths in custody need to be properly investigated and particular attention needs to be paid to unlawful deaths if and when they arise.

Polysubstance Overdose Deaths in the Fentanyl Era: A Latent Class Analysis.

To elucidate the main latent classes of substances detected among overdose decedents, and latent class associations with age, sex, race, and jurisdiction of death in Maryland. We used toxicology data from the Office of the Chief Medical Examiner of Maryland for all decedents. We analyzed all cases of drug overdose deaths that occurred from 2016 to 2018 (N = 6566) using latent class analysis and regression. Drug overdose deaths were concentrated in 2 of 24 counties in Maryland (Baltimore City and County). Fentanyl was involved in 71% of all drug overdose deaths, and the majority (76%) of these deaths included multiple substances. Three latent classes emerged: (1) fentanyl/heroin/cocaine (64%); (2) fentanyl/alcohol (18%); and (3) prescription drugs including opioids, benzodiazepines and antidepressants (18.0%). The fentanyl/heroin/cocaine class members were significantly younger (<30 years), female and White compared to the fentanyl/alcohol class, but more male and non-White than the prescription drugs class (all P < 0.05). Deaths in Baltimore City/County were more likely than in other locations to involve fentanyl/alcohol (P < 0.05). The majority of fentanyl-involved overdose deaths in Maryland involved multiple substances, and several demographic and geographic differences in these patterns emerged. Geographically-targeted interventions that are tailored to reduce the harms associated with polysubstance use (including cocaine, alcohol, and prescription drugs) for different demographic groups are warranted.

Variability in antemortem and postmortem blood alcohol concentration levels among fatally injured adults

ABSTRACT Background: Excessive alcohol use is a risk factor for injury-related deaths. Postmortem blood samples are commonly used to approximate antemortem blood alcohol concentration (BAC) levels. Objectives: To assess differences between antemortem and postmortem BACs among fatally injured adults admitted to one shock trauma center (STC). Method: Fifty-two adult decedents (45 male, 7 female) admitted to a STC in Baltimore, Maryland during 2006–2016 were included. STC records were matched with records from Maryland’s Office of the Chief Medical Examiner (OCME). The antemortem and postmortem BAC distributions were compared. After stratifying by antemortem BACs <0.10 versus ≥0.10 g/dL, differences in postmortem and antemortem BACs were plotted as a function of length of hospital stay. Results: Among the 52 decedents, 22 died from transportation-related injuries, 20 died by homicide or intentional assault, and 10 died from other injuries. The median BAC antemortem was 0.10 g/dL and postmortem was 0.06 g/dL. Thirty-one (59.6%) decedents had antemortem BACs ≥0.08 g/dL versus 22 (42.3%) decedents using postmortem BACs. Postmortem BACs were lower than the antemortem BACs for 42 decedents, by an average of 0.07 g/dL. Postmortem BACs were higher than the antemortem BACs for 10 decedents, by an average of 0.06 g/dL. Conclusion: Postmortem BACs were generally lower than antemortem BACs for the fatally injured decedents in this study, though not consistently. More routine antemortem BAC testing, when possible, would improve the surveillance of alcohol involvement in injuries. The findings emphasize the usefulness of routine testing and recording of BACs in acute care facilities.

Combat Stress Management and Resilience: Adapting Department of Defense Combat Lessons Learned to Civilian Healthcare during the COVID-19 Pandemic.

Combat Stress Management and Resilience: Adapting Department of Defense Combat Lessons Learned to Civilian Healthcare during the COVID-19 Pandemic.

The distribution and redistribution of carfentanil in post mortem samples

This article compares 290 post mortem case reports that were positive for carfentanil. All the cases were submitted to, and analyzed by, the toxicology department of the Office of the Chief Medical Examiner, Edmonton, Alberta, Canada. This study highlights the varied distribution of carfentanil in the body after death as a result of misadventure, i.e., these are accidental drug overdose cases.Post mortem samples were collected from more than one anatomical site and analysed for carfentanil using a validated liquid chromatography-tandem mass spectrometry method. Ante-mortem samples were available in 15 of these cases and were also analysed.Post mortem mean blood carfentanil concentrations were found to be 0.362 μg/L (femoral), 0.442 μg/L (iliac), 0.484 μg/L (cardiac) and 0.692 μg/L (subclavian). The mean vitreous humor carfentanil concentration was 0.238 μg/L; the mean urine carfentanil concentration was found to be 0.697 μg/L.Little difference was found between ligated and ‘blindstick’ femoral blood carfentanil concentrations. Whilst carfentanil can readily be detected in both vitreous humor and urine samples neither were found to correlate with blood concentrations, limiting their use in interpretation.This study demonstrates the importance of multi-site sample collection and subsequent analysis for a thorough post mortem toxicological investigation. The study also highlights the risks and limitations associated with the interpretation of post mortem analytical results concerning carfentanil.

Method Consolidation to Improve Scope and Efficiency in Postmortem Toxicology.

Systematic toxicological approaches that employ both ideology changes and improvements in instrumentation and sample extraction allow for improved toxicology testing efficiency through lower sensitivities, higher specificity and minimized resource use. Historically, the San Francisco Office of the Chief Medical Examiner relied heavily on a gas chromatography mass spectrometry (GC-MS) testing regime, comprised of individual drug-class confirmation and quantitation assays. Traditional methods utilizing GC-MS typically require iterations of testing, exhausting sample volume, and hindering productivity and turnaround times, particularly for polypharmacy cases frequently seen in modern postmortem toxicology. The method described here consolidated the scope of seven legacy methods into a single liquid chromatography tandem mass spectrometry (LC-MS/MS) method for better sensitivity, higher throughput, minimal sample consumption for the quantitation of drugs of abuse and improved quality assurance with the incorporation of smart, automated processing. About 100 μL of blood or urine were rapidly extracted using a simple acetonitrile protein crash and subsequent in-vial filtration and injected on to an LC-MS-MS system. The developed method was fully validated to SWGTOX and international guidelines and incorporated 55 analytes along with a customized query that facilitates rapid and consistent application of acceptability criteria for data processing and review. Applicability was demonstrated with the analysis of 1,389 samples (858 blood and 531 urine) where at least 41% of positive results may have been missed due to their decreased sensitivity and 11% of results were not within the scope of the previous analytical methods estimated. On average, cases in this study would have previously required three distinct GC-MS assays, 3mL of blood, and upwards of 30h of active staff time. The described LC-MS-MS analytical approach has mitigated the need to perform multiple assays, utilized only 0.1mL of sample, significantly reduced analyst work time, incorporated 10 additional analytes and allowed for a more comprehensive testing regime to better inform cause of death determinations.

Discovery Context of Skeletal Remains Received at the Federal Bureau of Investigation Laboratory

Cases received for anthropological examination by the Federal Bureau of Investigation (FBI) Laboratory for a 4-year period (2013–2017) were reviewed for the context of the discovery of remains. The assessment was compared with a previous similar review of cases received by the Massachusetts Office of the Chief Medical Examiner (OCME), with particular attention to whether remains were initially discovered through deliberate law enforcement searches or inadvertently discovered by others. Results show that 52.9% of FBI Laboratory anthropology cases were initially discovered by law enforcement, compared to only 3.6% of Massachusetts OCME cases. Reasons for this difference are discussed, as well as other similarities and differences in discovery mode and context for anthropology cases between these two laboratories.

Determining Youth Intentional Fatal Drug Intoxication: The Case for a Psychological Autopsy to Complement the Medical Examiner’s Report

Background Opioids and cocaine are the leading drugs for fatal drug intoxication (FDI). Manner of death may be accidental (i.e., unintentional); suicide (i.e., intentional), or undetermined. Difficulties of the medical examiner (ME) in confirming the manner of death by a standard investigation may result in underreporting of intentional FDI thus limiting efforts to identify, reduce, and prevent it. Objective Examine the rate of youth intentional and undetermined FDI and address the need for closing the gap in the determination of intentional FDI among youths by the addition of a psychological autopsy. Method Two hundred ninety-three (293) consecutive FDI case files from the State of Connecticut Office of the Chief Medical Examiner were reviewed. The case files were those of youths, 10 to 25 years of age, who died between January 1, 2016, and December 31, 2018. Results The annual intentional FDI rates among this group were between 3% and 5%. Undetermined manner of death rates were between 0% and 5% percent, while the remaining cases was reported as accidental. A majority of the FDI cases involved youths 20 to 25.11 years old, while a small percentage were among those ages 15 to 19.11 and none for 10 to 14.11. Male-to-female ratio was approximately 2:1 in all categories of FDI. Conclusion These low rates of intentional FDI among youths support the arguments regarding limitations in the procedures employed by a ME to determine intent. There is a need for an individual-level study of a multipronged approach to identify modifiable acute high-risk circumstances for intentional FDI, including a psychological autopsy.

Trends in opioid use disorder and overdose among opioid‐naive individuals receiving an opioid prescription in Massachusetts from 2011 to 2014

To examine how the risks of incident opioid use disorder (OUD), non-fatal and fatal overdose have changed over time among opioid-naive individuals receiving an initial opioid prescription. Retrospective, longitudinal study using the Massachusetts Chapter 55 data set, which linked multiple administrative data sets to study the opioid epidemic. We identified the cumulative incidence of OUD, non-fatal and fatal overdose among the opioid-naive initiating opioid treatment in Massachusetts from 2011 to 2014 and estimated rates of these outcomes at 6months and at 1, 2, 3 and 4years to 2015. We used Cox regression to examine the association between characteristics of the initial prescription and risk of these outcomes. Massachusetts, USA. Massachusetts residents aged ≥11years in 2011-15 who were opioid-naive (no opioid prescriptions or evidence of OUD in the 6months prior to the index prescription) (n=2 154 426). The mean age was 49.1years, 55.3% were female and 47.3% had commercial insurance. Opioid prescriptions were identified in the Prescription Monitoring Program (PMP) database, as were the characteristics of the initial prescription database. The outcomes of OUD and non-fatal overdose were identified from claims in the All Payer Claims Database (APCD) and hospital encounters in the acute hospital case mix files. Fatal overdoses were identified using Registry of Vital Records and Statistics (RVRS) death certificates and the Office of the Chief Medical Examiner (OCME) circumstances of death and toxicology reports. Among opioid-naive individuals receiving an initial opioid prescription, the risk of incident OUD appears to have declined between 2011 and 2014, while rates of overdose were largely unchanged. For example, the 1-year OUD rate was 1.18% in 2011, 1.11% in 2012, 1.26% in 2013 and 0.94% in 2014. Longer therapy duration was associated with higher risk of OUD [hazard ratio (HR)=2.24, 95% confidence interval (CI)=2.19-2.29 for duration of 3 or more months], non-fatal (HR=1.67, 95% CI=1.53-1.82) and fatal opioid overdose (HR=2.24, 95% CI=1.91-2.61). Concurrent benzodiazepine treatment was also associated with higher risk of OUD (HR=1.14, 95% CI =1.12-1.17), non-fatal (HR=1.20, 95% CI=1.10-1.30) and fatal overdose (HR=1.86, 95% CI =1.61-2.16). Among opioid-naive individuals in Massachusetts receiving an initial opioid prescription, the risk of incident opioid use disorder appears to have declined between 2011 and 2014, while rates of overdose were largely unchanged. Longer therapy duration and concurrent benzodiazepines were associated with higher rates of opioid use disorder and opioid overdose.

Predicting Opioid Overdose Deaths Using Prescription Drug Monitoring Program Data

Prescription Drug Monitoring Program data can provide insights into a patient's likelihood of an opioid overdose, yet clinicians and public health officials lack indicators to identify individuals at highest risk accurately. A predictive model was developed and validated using Prescription Drug Monitoring Program prescription histories to identify those at risk for fatal overdose because of any opioid or illicit opioids. From December 2018 to July 2019, a retrospective cohort analysis was performed on Maryland residents aged 18-80 years with a filled opioid prescription (n=565,175) from January to June 2016. Fatal opioid overdoses were identified from the Office of the Chief Medical Examiner and were linked at the person-level with Prescription Drug Monitoring Program data. Split-half technique was used to develop and validate a multivariate logistic regression with a 6-month lookback period and assessed model calibration and discrimination. Predictors of any opioid-related fatal overdose included male sex, age 65-80 years, Medicaid, Medicare, 1 or more long-acting opioid fills, 1 or more buprenorphine fills, 2 to 3 and 4 or more short-acting schedule II opioid fills, opioid days' supply ≥91 days, average morphine milligram equivalent daily dose, 2 or more benzodiazepine fills, and 1 or more muscle relaxant fills. Model discrimination for the validation cohort was good (area under the curve: any, 0.81; illicit, 0.77). A model for predicting fatal opioid overdoses was developed using Prescription Drug Monitoring Program data. Given the recent national epidemic of deaths involving heroin and fentanyl, it is noteworthy that the model performed equally well in identifying those at risk for overdose deaths from both illicit and prescription opioids.