Staying Ahead of Overdose Spikes

According to an recent issue brief from the American Medical Association, 35 states across the nation have reported spikes in opioid-related deaths since the start of the COVID-19 pandemic in the United States (US). While the nation is (rightly) marshaling resources to contain the COVID-19 outbreak some public health experts worry that any gains made in combating opioid-related overdoses have been reversed and may not recover for a long time. Fortunately, local government agencies have access to a free tool that can be used to map clusters of fatal and non-fatal overdoses, which may help to predict when and where the next spike will occur.

Background

A staggering quarter of a million people in the U.S. have died from an opioid overdose from 1999-2018. According to the Centers for Disease Control and Prevention (CDC) this rise can be outlined in three distinct waves.

• The first wave began with increased prescribing of opioids in the 1990s, with overdose deaths {involving prescription opioids} increasing since at least 1999.
• The second wave began in 2010, with rapid increases in overdose deaths involving heroin.
• The third wave began in 2013, with significant increases in overdose deaths involving synthetic opioids, particularly those involving illicitly manufactured fentanyl.

For the first time in years, the CDC released data this January showing a slight decline in fatal overdoses nationwide. However, the arrival of the coronavirus epidemic has brought a sudden halt to this positive trend. A May 13 report from the Office of National Drug Control Policy found close to an 11.4% increase in fatal overdoses and an 18.6% increase in non-fatal overdoses during January through April 2020 (compared to the same time frame in 2019) using county-level data from six different states.

What Accounts for the Recent Rise?

People with substance use disorder already face obstacles to accessing treatment, but there are three significant ways that the COVID-19 pandemic has further complicates matters: Restricted access to resources, social isolation, and supply chain disruption.

Restricted access to treatment

Stay-at-home orders have created barriers to treatment, with medication-assisted treatment clinics reducing hours, closing, or offering fewer resources. Some clinics and treatment centers have opted for mobile services and delivery, but many are resource poor, making the sudden switch challenging. In April, the Substance Abuse and Mental Health Services Administration and Drug Enforcement Administration amended rules to allow increased flexibility for providing buprenorphine and methadone to patients with opioid use disorder: Providers can now prescribe buprenorphine across state lines without an initial in-person evaluation (e.g., telehealth visits are approved) and can also provide larger doses of take-home medications.

Social isolation adds to existing instability

Addiction is already known as a disease of loneliness and disconnection. Compound that with the fear and uncertainty associated with COVID-19-related social and economic distress and some people will self-medicate with drugs and alcohol to ease the stress, anxiety, and depression that arises. Isolated individuals are, in turn, at increased risk of fatally overdosing. Narcotics Anonymous and other similar recovery groups have largely switched to online and video meetings, but the strong social networks so critical to addiction recovery are being tested in the current climate.

Disrupted supply chains strain resources

Supply chain disruptions are causing opioid-related shortages, impacting both the medical community and the black market for illegal drugs. Coronavirus shutdowns and hospital overcrowding are limiting access to essential medications and services that people who are addicted to opioids rely on, leading to reports of drug stockpiling. Further, a reduction in exports and new travel restrictions to the U.S. have led to a hike in illicit drug prices. Persons addicted to opioids are especially at risk, as illicitly manufactured (and potentially deadly) fentanyl is often found in combination with heroin and counterfeit opioid prescription pills that resemble Oxycodone or Xanax.

Predicting Outbreaks

This past April, Seattle and King County saw an increase in fatal overdoses from fentanyl mixed with tainted pills and a similar spike in overdose rates in May, this time from black tar heroin mixed with fentanyl. Fentanyl is a synthetic opioid that is sold illegally in powder form, making it easy to mix tiny quantities into another drug. It’s 50-100 times more potent than morphine but far cheaper and easier to obtain, giving dealers plenty of incentive to add it to other, more expensive narcotics. When fentanyl-laced narcotics show up on city streets what often follows is a clustering of overdoses and a spike in the rate, which is likely to be repeated in neighboring jurisdictions days or weeks later. The pattern is similar to an epidemiology map with patient zero at the center, extending to disease clusters/outbreaks identified nearby at a later date.

It should be noted that while the CDC uses a variety of data sources to monitor fatal opioid overdose rates, there is no centralized system that federal and state agencies use to collect overdose data in real or near-real time. With such a system, an agency could quickly identify overdose clusters and outbreaks within its own jurisdiction and use this information to alert nearby communities to martial the people (hospitals, social workers, first responders) and resources (outreach, education, naloxone) to prepare for a spike in their jurisdictions.

Overdose Data Mapping Application Program

In 2017, the Washington D.C./Baltimore High Intensity Drug Trafficking Area (HIDTA) rolled out the Overdose Detection Mapping Application Program (ODMAP), a mapping software program that collects real time, county-level fatal and non-fatal opioid overdose data from ambulance teams, hospitals, and law enforcement. Participation in ODMAP is open to “state, local, federal and tribal agencies serving the interests of public safety and health as part of their official mandate, including licensed first responders and hospitals.” Today, 3,300 agencies in 49 states use ODMAP, including here in Washington, where 34 agencies, including counties; county departments (health, coroner’s office, sheriff); city police and fire departments; and rural fire and rescue groups share data with ODMAP. 

How it works

ODMAP focuses exclusively on logging and tracking overdoses in real-time, which allows the system to find patterns in overdose data and predict new spikes and clusters.

ODMAP is free to all users and offers two levels of usership depending on how agency users will interact with the system. Anyone filing a report (e.g.,. first responder, police officer, or a designee) is a Level 1 user who must log in to ODMAP via a password-protected web portal. A first responder will report fatal and non-fatal overdoses, the time and location, and will also record if naloxone was administered (and the dosage). Police will complete a different form on which they can record a victim’s personal information (date of birth; overdose history) and situational information (eyewitness testimony; type of drug causing the overdose; evidence found at the scene). This data can be cross-referenced with previous overdose reports to allow reporting officers from different agencies to coordinate any follow-up, such as further investigation.

The data provided by agency users can then be mapped to help identify possible correlations between clusters and spikes, predict new cluster, or to connect individual instances of non-fatal overdoses across city, county, or even state lines. Analytics on overdose outbreaks are available to Level 2 users (sheriffs and public health chiefs) via ODMAP Box, which requires a separate username and password. A sheriff can log in to get a bird's-eye view of recorded overdose incidents — in the form of color-coded blips — across a map of the U.S. Accessing localized data is as simple as zooming in on a specific point on the map. 

In addition to being able to spot overdose clusters in one area and predict possible spikes in neighboring areas, agencies have used ODMAP to:

• Guide procurement and use/distribution of naloxone,
• Increase/improve data sharing with other agencies,
• Increase monitoring or patrolling of areas where there are a large number of overdoses,
• Identify where and when to investigate trends in narcotics distribution, and
• Guide outreach efforts to persons at risk for overdose and/or their support networks.

For more information

To begin, agencies must sign the ODMAP Participation Agreement and designate an agency administrator who will manage the agency’s ODMAP access and individual account holders. Since the application’s predictive and analytical tools are made more powerful through agency data, ODMAP provides a host of support to entice agencies to join. It's public-facing website features a Training section that includes a FAQ sheet, training manual, ODFORM tutorial, and multiple links to the program's YouTube channel, where it hosts general videos about the program as well as training videos directed at Level 1 or Level 2 users.