Article, Toxicology

Syndrome surveillance of fentanyl-laced heroin outbreaks: Utilization of EMS, Medical Examiner and Poison Center databases

a b s t r a c t

Objective: Describe surveillance data from three existing surveillance systems during an unexpected fentanyl out- break in a large metropolitan area.

Methods: We performed a retrospective analysis of three data sets: Chicago Fire Department EMS, Cook County Medical Examiner, and Illinois Poison Center. Each included data from January 1, 2015 through December 31, 2015. EMS data included all EMS responses in Chicago, Illinois, for suspected opioid overdose in which naloxone was administered and EMS personnel documented other criteria indicative of opioid overdose. Medical Examiner data included all deaths in Cook County, Illinois, related to heroin, fentanyl or both. Illinois Poison Center data in- cluded all calls in Chicago, Illinois, related to fentanyl, heroin, and other Prescription opioids. Descriptive statistics using Microsoft Excel(R) were used to analyze the data and create figures.

Results: We identified a spike in opioid-related EMS responses during an 11-day period from September 30-

October 10, 2015. Medical Examiner data showed an increase in both fentanyl and mixed fentanyl/heroin related deaths during the months of September and October, 2015 (375% and 550% above the median, respectively.) Il- linois Poison Center data showed no significant increase in heroin, fentanyl, or other opioid-related calls during September and October 2015.

Conclusion: Our data suggests that EMS data is an effective real-time surveillance mechanism for changes in the rate of opioid overdoses. Medical Examiner’s data was found to be valuable for confirmation of EMS surveillance data and identification of specific intoxicants. Poison Center data did not correlate with EMS or Medical Examiner data.

(C) 2017

Introduction

Background

According to the Centers for Disease Control and Prevention (CDC), the United States is experiencing an epidemic of drug overdose deaths, with a 200% increase in opioid-related deaths since 2000 [1]. While pre- scription opioids remain the largest killer, there has been a recent surge in deaths driven by heroin and fentanyl [1]. Between 2013 and 2014, age-adjusted opioid related Death rates increased by 9% for opioid pain relievers, 26% for heroin, and an alarming 80% for fentanyl [1]. Cities across the U.S. are struggling to combat the latest phase of the opi- oid epidemic.

* Corresponding author.

E-mail addresses: [email protected] (P.Q. Moore), [email protected] (J. Weber), [email protected] (S. Cina), [email protected] (S. Aks).

1 4883 Valley Oak Dr, Loveland, CO, 80538.

Importance

In March 2015, the Drug Enforcement Agency issued a nationwide alert on the resurgence of fentanyl and its threat to public health and safety [2]. In September and October 2015, the City of Chicago and other areas of the U.S. experienced a surge of fentanyl-related deaths. In response, the Health Alert Network (HAN) released two separate CDC Health Advisories with recommendations for improved detection of fentanyl outbreaks to facilitate effective response to the rising num- ber of opioid-related deaths [3,4]. Specifically, the use of existing sur- veillance systems such as emergency medical services (EMS), medical examiners, and local Poison Center data was advised [3,4].

Goals of this investigation

In this paper, we describe the data from these three surveillance sys- tems and how these data reflect the role of each agency in the coordi- nated response to the aforementioned fentanyl outbreak.

http://dx.doi.org/10.1016/j.ajem.2017.05.003

0735-6757/(C) 2017

P.Q. Moore et al. / American Journal of Emergency Medicine 35 (2017) 17061708 1707

Methods

Study design and setting

We performed a cross-sectional retrospective analysis of three data sets: Chicago Fire Department EMS response, Cook County Medical Ex- aminer, and Illinois Poison Center. Each included data from January 1, 2015 through December 31, 2015. Exemption was granted by the hospi- tal Institutional Review Board.

Selection of participants

EMS data included all EMS responses in Chicago, Illinois, for suspected opioid overdose in which naloxone was administered and EMS personnel documented other criteria indicative of opioid overdose. Medical Examiner data included all deaths in Cook County, Illinois, re- lated to heroin, fentanyl or both. Illinois Poison Center data included all calls in Cook County, Illinois related to fentanyl, heroin, and other prescription opioids.

Analysis

Descriptive statistics using Microsoft Excel(R) were used to analyze the data and create figures.

Results

Chicago EMS response data showed a spike in responses for suspected opioid overdose during an eleven-day period from Septem- ber 30th through October 10th, 2015 (Fig. 1.) Medical Examiner data showed an increase in both fentanyl and mixed fentanyl/heroin related deaths during the months of September and October 2015 (375% and 550% above the median, respectively, Fig. 2). Illinois Poison Center data showed no significant increase in heroin, fentanyl, or other opi- oid-related calls during September and October 2015.

Discussion

Limitations

Our study describes just one city’s surveillance data focusing on a single fentanyl outbreak. Given the variable nature of EMS, Medical Examiner’s, and poison centers, the generalizability to other areas of the country may be limited. Our data are also insufficient to demon- strate the influence of each surveillance system’s data on the effective- ness of the city’s response to the fentanyl outbreak.

Fig. 2. Cook County Medical Examiner’s office: deaths related to heroin and fentanyl.

Discussion

Our findings illustrate the role of each agency in identifying and responding to unexpected outbreaks of fentanyl overdose. We found EMS data to be an excellent real-time surveillance mechanism for changes in the rate of opioid overdoses. These results are consistent with previous studies that examined EMS response and naloxone ad- ministration data as indicators of opioid overdose rates [5,6]. The Med- ical Examiner’s data, while later to arrive because send-out toxicologic testing was required, proved to be a valuable tool for confirmation of EMS surveillance data and identification of specific intoxicants.

Interestingly, Poison Center data did not correlate with EMS or Med- ical Examiner data. This is likely a reflection of the comfort that most medical providers have in treating opioid toxicity in emergency set- tings. We did find, however, that input from toxicologists helped guide the response to the outbreak. Specifically, front-line clinicians were counseled that recognition of an opioid toxidrome, in the presence of negative standard urine toxicologic testing for opiates, was sugges- tive of the ultra-potent opioid fentanyl or one of its derivatives. Stan- dard toxicology screens test for opiates (morphine derivatives), but not Synthetic opioids such as fentanyl.

Finally, our data suggest that inter-agency collaboration and data sharing is helpful in identifying, responding to, and mitigating unex- pected outbreaks of fentanyl overdoses. Chicago EMS, the Cook County Medical Examiner’s office and the Illinois Poison Center now regularly share data in an attempt to continue surveillance of the city’s fentanyl epidemic. We propose that other regions develop similar collaborative networks to facilitate rapid response to unpredicted outbreaks in drugs of abuse.

Fig. 1. Chicago Fire Department EMS responses for suspected opioid overdose.

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Sources of support

This research did not receive any specific grant from funding agen- cies in the public, commercial, or not-for-profit sectors.

Previous publication or presentation

None.

Conflicts of interest

None.

Author contribution statement

JW conceived the study and obtained the data. PQM, JW and SA designed the study and performed the analysis. JW and SA drafted the manuscript. SA, JW, and SC provided the data. All authors contributed substantially to revision of the manuscript.

Acknowledgments

We wish to acknowledge Leslee Stein-Spencer, RN, MS, and Michael Wahl, MD, for their contributions in providing the data that made this paper possible.

References

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