Opioid Data Lab Understanding Overdose Through Scientific Innovation

Methodology for polysubstance drug overdose identification and reporting Description Narrative: There is an urgent need to develop standardized methods for identifying and reporting polysubstance overdose to inform our understanding of the drug overdose epidemic and ensure an appropriate public health response. Increasing rates of polysubstance use and unintentional polysubstance exposure underlie the evolving drug overdose epidemic in the US (Jones), but there is no consensus definition for polysubstance drug overdose, nor is there agreement for classifying whether a drug overdose death is due to one or multiple substances. Nationally, the reporting of drug involvement in overdose deaths is based on the most commonly involved drugs or drug classes using the ICD-10-coded multiple causes of death or the literal text analysis of the death certificates (Hedegaard 2018, Hedegaard 2020). Previous work conducted by the NCHS, CSTE and FDA (Trinidad, Davis, Hedegaard 2018) developed SAS programming tools to process the literal text on death certificates to identify mentioning of specific drugs and drug involvement in the death based on the contextual information. These programming tools use a list of drug search terms (e.g., generic and brand names, misspellings, metabolites), with each search term mapped to a principal variant for reporting purposes. Based on the frequency distribution of the principal variants for U.S. deaths from 2011 to 2016, the NCHS created a referent drug group for the top 20 drugs, with some drug groups including multiple principal variants. The referent drug groups have been used by the NCHS as a framework for reporting of drugs most frequently involved in drug overdose deaths (Hedegaard 2018). The current NCHS reporting framework is no longer adequate considering the changing drug market (e.g., doesn’t distinguish between fentanyl and fentanyl analogs). The most complete publicly available search term list was developed by the NCHS five years ago and is outdated as no agency/research group has dedicated resources for updating it. The UK research team, as part of the FDA BAA-17-00123- funded work, identified more than one thousand new search terms. Public health agencies and researchers use the CSTE and NCHS programing tools for literal text search but use different approaches to count the most frequent drugs involved in mortality (e.g., based on principal variants or referent drug groups), and use study-specific definitions to characterize a drug overdose death as a single- vs polydrug-involved death. These limitations provide challenges for standardization and comparison of results reported by jurisdictions or research studies. Furthermore, no methodological work has been done to evaluate the harmonization of drug-involved mortality reporting with reporting by other countries. We propose the following work that would advance the consistency and comparability of drug overdose mortality reporting: Aim 1: Develop and maintain a publicly available up-to-date list of drug search terms mapped to principal variants and updated referent drug groups. Periodic updating of search terms and text search capabilities is essential for the ongoing surveillance and monitoring of emerging trends in drug overdose deaths. Aim 2: Develop recommendations/framework for reporting of drug involvement in drug overdose deaths building on the collaborative work between the NCHS and the FDA. Test these recommendations with KY data and revise the framework based on the findings. Aim 3: Develop recommendations (including conceptual and operational definitions) for single drug- vs polydrug- overdose death classification based on the information listed on a death certificate. Validate the proposed recommendations using death certificates, supplemented with toxicology, coroner reports, and other medico-legal death investigation documents for KY drug overdose decedents. The proposed work will be guided by Dr. Holly Hedegaard, one of the developers of the national drug- involved mortality reporting framework, and Dr. Bruce Goldberger, the leading author on the recommendations for classifying opioid-related deaths by a SAMHSA’s consensus panel. Dr. Delcher will collaborate on the Algorithms project that will be delivered by a team from the UNC. Key Outputs: + Updated list of drug search terms mapped to principal variants and updated referent drug groups + Guidance document detailing operational definitions and proposed reporting framework + Manuscript