Lawrence Scholl’s research while affiliated with Centers for Disease Control and Prevention and other places

Context: The Centers for Disease Control and Prevention (CDC) developed a syndrome definition for detection of suspected nonfatal cocaine-involved overdoses. The definition can be used to monitor trends and detect anomalies in emergency department (ED) syndromic surveillance data at the national, state, and local levels. Objective: This study describes the development of the nonfatal, unintentional/undetermined intent cocaine-involved overdose (UUCOD) definition and analysis of trends over time. Design/setting: CDC developed the UUCOD definition to query ED data in CDC's National Syndromic Surveillance Program (NSSP). Data between 2018 and 2021 were analyzed from 29 states sharing data access in the Drug Overdose Surveillance and Epidemiology (DOSE) System via NSSP. Using Joinpoint regression, trends were analyzed for UUCOD overall, by sex and age group, and for UUCOD co-involving opioids. Measures: Time trends between 2018 and 2021 were analyzed by examining average monthly percentage change. Individual trend segments and trend inflection points were analyzed by examining monthly percentage change. Results: During 2018-2021, a total of 27 240 UUCOD visits were identified by the syndrome definition. Analyses identified different patterns in trends for males and females, with largely similar trends for persons aged 15 to 44 years and 45 years or older. Analyses also identified seasonal patterns with increases in spring/summer months in UUCOD overall and UUCOD co-involving opioids and declines for both in fall/winter months. Conclusion: This UUCOD syndrome definition will be useful for ongoing monitoring of suspected nonfatal overdoses involving cocaine and co-involving cocaine and opioids. Ongoing assessment of cocaine-involved overdose trends might identify anomalies requiring further investigation and inform deployment of resources.

Synthetic opioids, including illicitly manufactured fentanyls, are driving recent increases in US overdose deaths. Beginning October 2020, the International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM) code for poisonings involving synthetic narcotics (T40.4X) was split into three codes: fentanyl (T40.41), tramadol (T40.42), and other synthetic narcotics (T40.49). Emergency department data from October 2019–September 2021 in the Centers for Disease Control and Prevention’s National Syndromic Surveillance Program BioSense platform were queried for synthetic opioid codes in the chief complaint and discharge diagnosis fields. Trend analyses assessed average monthly percent change overall and by sex and age. Emergency department visits for overdoses involving synthetic narcotics increased on average 3.2 % each month before the code split and 4.8 % after. Visits with fentanyl codes drove this increase after the split, accounting for most visits among males, females, and every age group except ≥ 65 years. The average monthly percent increase for ED visits for fentanyl-involved overdoses was greater than for all synthetic narcotics combined (i.e., T40.41, T40.42, and/or T40.49), suggesting that the old code (T40.4X) masked the full extent of the increase in ED visits for fentanyl overdoses. Usage of these new codes can improve tracking of non-fatal synthetic opioid overdose trends.

Objectives To monitor stimulant-involved overdose (SOD) trends, the Centers for Disease Control and Prevention (CDC) developed and evaluated the validity of a syndromic surveillance definition for suspected nonfatal, unintentional/undetermined intent stimulant-involved overdose (UUSOD). Methods We analyzed all emergency department (ED) visits in CDC’s surveillance system that met the UUSOD syndrome definition (January 2018–December 2019). We classified visits as true positive, possible, or not UUSODs after reviewing diagnosis codes and chief complaints. We first assessed whether visits were acute SODs, subsequently classifying acute SODs by intent. The percentage of true-positive UUSODs did not include intentional or possibly intentional visits. We considered all visits with UUSOD diagnosis codes to be acute SODs and reviewed them for intent. We manually reviewed and double-coded a 10% random sample of visits without UUSOD diagnosis codes using decision rules based on signs and symptoms. The overall percentage of true-positive UUSODs was a weighted average of the percentage of true-positive UUSODs based on diagnosis codes and the percentage of true-positive UUSODs determined by manually reviewing visits without codes. Results During 2018-2019, 40 045 ED visits met the syndrome definition for UUSOD. Approximately half (n = 18 793; 46.9%) of 40 045 visits had UUSOD diagnosis codes, indicating acute SOD; of these, 98.6% (n = 18 534) were true-positive UUSODs. Of 2125 manually reviewed visits without UUSOD diagnosis codes, 32.6% (n = 693) were true-positive UUSODs, 54.2% (n = 1151) were possible UUSODs, and 13.2% (n = 281) were not UUSODs. Overall, 63.6% of visits were true-positive UUSODs, 29.3% were possible UUSODs, and 7.1% were not UUSODs. Practice Implications CDC’s UUSOD definition may assist in surveillance efforts with further refinement to capture data on SOD clusters and trends.

Introduction Nonfatal and fatal drug overdoses have recently increased. There are limited data describing the range of illicit, prescribed, and over-the-counter drugs involved in overdoses presenting to U.S. emergency departments (EDs). Methods Using 2018 Healthcare Cost and Utilization Project (HCUP) Nationwide ED Sample (NEDS) data, we calculated weighted counts and percentages by drug among overdose-related ED visits. Overdose-related ED visits were those having an International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) drug poisoning code falling under parent codes T36-T50 (codes involving alcohol were not explicitly queried). We identified the top 30 mutually exclusive polydrug combinations and compared characteristics of visits by polydrug status. Results In 2018, 908,234 ED visits had a T36-T50 drug poisoning code. The most frequently reported drugs involved were opioids (30.3% of visits; heroin: 15.2%), benzodiazepines (11.0%), stimulants (7.9%), other/unspecified antidepressants (7.1%), 4-aminophenol derivatives (6.6%), and other/unspecified drugs, medicaments, and biological substances (11.8%). Overdose was uncommon for most other drug classes (e.g., antibiotics). Polydrug visits were more likely to involve females (prevalence ratio [PR]: 1.14, 95% confidence interval [CI]: 1.12-1.16), be coded intentional self-harm (PR: 1.81, 95% CI: 1.77-1.85), and result in hospitalization (PR: 1.84, 95% CI: 1.79-1.89) or death (PR: 1.37, 95% CI: 1.22-1.53) compared to single-drug overdose-related visits. Benzodiazepines, opioids, and/or stimulants were most frequently involved in polydrug overdoses. Conclusion Opioids, benzodiazepines, and stimulants were most commonly reported in both single-drug and polydrug overdose-involved ED visits. Other drugs involved in overdoses included antidepressants and 4-aminophenol derivatives. Jurisdictions can use data on drugs involved in overdoses to better tailor prevention strategies to emerging needs.

Background Drug overdose deaths involving stimulants, including cocaine and psychostimulants with abuse potential (e.g., methamphetamine), have been increasing, partly because of co-involvement with opioids. Stimulant-involved overdoses deaths have disproportionately increased among non-Hispanic Black (Black) and non-Hispanic American Indian/Alaskan Native (AI/AN) persons; however, the role of opioids in exacerbating disproportionate stimulant-involved death rates is unclear. Methods Analysis of National Vital Statistics System multiple cause-of-death mortality files examined age-adjusted cocaine- and psychostimulant-involved death rates. Analyses of death rates stratified by racial and ethnic group and opioid co-involvement included: 1) Joinpoint regression of 2004–2019 trends, 2) changes in rates from 2018 to 2019, and 3) demographic and geographic characteristics of 2019 deaths. Results from 2004 to 2019, cocaine and psychostimulant-involved death rates were higher for Black and AI/AN persons, respectively. Among all groups, increases in cocaine-involved overdose rates were largely driven by opioid co-involvement, particularly after 2013. From 2004 to 2019, rates for psychostimulant-involved deaths increased with and without opioid co-involvement. Rates for overdoses co-involving cocaine and synthetic opioids increased from 2018 to 2019 for Hispanic, non-Hispanic White (White), and Black persons. Psychostimulant-involved overdose rates with and without synthetic opioid co-involvement increased among Hispanic, White, and Black persons. In 2019, Black and AI/AN persons continued to experience higher cocaine- and psychostimulant-involved death rates, respectively. Conclusions Stimulant-involved deaths continue to increase, and the role of opioids in driving these deaths varies by race and ethnicity. Ensuring equitable access to proven prevention and treatment interventions and incorporating social determinants of health into future research around effective pharmacotherapies may help reduce stimulant-involved overdose deaths.

Purpose Emergency department (ED) syndromic surveillance and hospital discharge data have been used to detect and monitor nonfatal drug overdose, yet few studies have assessed the differences and similarities between these two data sources. Methods The Centers for Disease Control and Prevention Drug Overdose Surveillance and Epidemiology (DOSE) system data from 14 states were used to compare these two sources at estimating monthly overdose burden and trends from January 2018 through December 2019 for nonfatal all drug, opioid-, heroin-, and stimulant-involved overdoses. Results Compared to discharge data, syndromic data captured 13.3% more overall ED visits, 67.8% more all drug overdose visits, 15.6% more opioid-involved overdose visits, and 78.8% more stimulant-involved overdose visits. Discharge data captured 18.9% more heroin-involved overdoses. Significant trends were identified for all drug (Average Monthly Percentage Change [AMPC]=1.1, 95% CI=0.4,1.8) and stimulant-involved overdoses (AMPC=2.4, 95% CI=1.2,3.7) in syndromic data; opioid-involved overdoses increased in both discharge and syndromic data (AMPCDischarge=0.9, 95% CI=0.2,1.7; AMPCSyndromic=1.9, CI=1.1,2.8). Conclusions Results demonstrate that discharge data may be better for reporting counts, yet syndromic data are preferable to detect changes quickly and to alert practitioners and public health officials to local overdose clusters. These data sources do serve complementary purposes when examining overdose trends.

Context: The Centers for Disease Control and Prevention (CDC) works closely with states and local jurisdictions that are leveraging data from syndromic surveillance systems to identify meaningful changes in overdose trends. CDC developed a suspected nonfatal heroin overdose syndrome definition for use with emergency department (ED) data to help monitor trends at the national, state, and local levels. Objective: This study assesses the percentage of true-positive unintentional and undetermined intent heroin-involved overdose (UUHOD) captured by this definition. Design/setting: CDC applied the UUHOD definition to ED data available in CDC's National Syndromic Surveillance Program (NSSP). Data were analyzed from 18 states that shared access to their syndromic data in NSSP with the CDC overdose morbidity team. Data were analyzed using queries and manual reviews to identify heroin overdose diagnosis codes and text describing chief complaint reasons for ED visits. Measures: The percentage of true-positive UUHOD was calculated as the number of true-positives divided by the number of total visits captured by the syndrome definition. Results: In total, 99 617 heroin overdose visits were identified by the syndrome definition. Among 95 323 visits identified as acute heroin-involved overdoses, based on reviews of chief complaint text and diagnosis codes, 967 (1.0%) were classified as possible intentional drug overdoses. Among all 99 617 visits, 94 356 (94.7%) were classified as true-positive UUHOD; 2226 (2.2%) and 3035 (3.0%) were classified as "no" and "maybe" UUHOD, respectively. Conclusion: Analysis of the CDC heroin overdose syndrome definition determined that nearly all visits were captured accurately for patients presenting to the ED for a suspected acute UUHOD. This definition will continue to be valuable for ongoing heroin overdose surveillance and epidemiologic analysis of heroin overdose patterns. CDC will evaluate possible definition refinements as new products and terms for heroin overdose emerge.

The U.S. drug overdose epidemic continues to cause substantial morbidity and mortality. In 2017, 967,615 nonfatal drug overdoses were treated in emergency departments (EDs), a 4.3% increase from 2016 in all overdoses and a 3.1% increase in opioid-involved overdoses (1). During 2017 and 2018, syndromic surveillance revealed that 37.2% of overdoses treated in EDs in 18 states involved multiple drugs (2). To describe changes in rates and proportions of suspected nonfatal drug and polydrug overdoses treated in EDs, CDC analyzed syndromic surveillance data from 2018 to 2019 in 29 states. Rates of overdoses involving opioids, cocaine, and amphetamines increased 9.7%, 11.0%, and 18.3%, respectively, and the rate of benzodiazepine-involved overdoses decreased 3.0%. Overdoses co-involving opioids and amphetamines increased from 2018 to 2019, overall, in both sexes, and in most age groups. In 2019, 23.6%, 17.1%, and 18.7% of overdoses involving cocaine, amphetamine, and benzodiazepines, respectively, also involved opioids. Expanding overdose prevention, treatment, and response efforts is needed to reduce the number of drug and polydrug overdoses. This includes linkage into treatment, harm reduction services, and community-based programs for persons who use drugs; expanding overdose prevention efforts, including increased naloxone provision, to persons who use stimulants; addressing the illicit drug supply; and identifying specific risk factors for populations using these drugs. Continued surveillance with expanded coverage of additional jurisdictions of the evolving drug overdose epidemic is important to the success of these efforts.

In 2017, drug overdoses caused 70,237 deaths in the United States, a 9.6% rate increase from 2016 (1). Monitoring nonfatal drug overdoses treated in emergency departments (EDs) is also important to inform community prevention and response activities. Analysis of discharge data provides insights into the prevalence and trends of nonfatal drug overdoses, highlighting opportunities for public health action to prevent overdoses. Using discharge data from the Healthcare Cost and Utilization Project's (HCUP) Nationwide Emergency Department Sample (NEDS), CDC identified nonfatal overdoses for all drugs, all opioids, nonheroin opioids, heroin, benzodiazepines, and cocaine and examined changes from 2016 to 2017, stratified by drug type and by patient, facility, and visit characteristics. In 2017, the most recent year for which population-level estimates of nonfatal overdoses can be generated, a total of 967,615 nonfatal drug overdoses were treated in EDs, an increase of 4.3% from 2016, which included 305,623 opioid-involved overdoses, a 3.1% increase from 2016. From 2016 to 2017, the nonfatal overdose rates for all drug types increased significantly except for those involving benzodiazepines. These findings highlight the importance of continued surveillance of nonfatal drug overdoses treated in EDs to inform public health actions and, working collaboratively with clinical and public safety partners, to link patients to needed recovery and treatment resources (e.g., medication-assisted treatment).

In 2016, a total of 63,632 persons died from drug overdoses in the United States (1). Drug overdose deaths involving cocaine, psychostimulants with abuse potential (psychostimulants), or both substances combined increased 42.4% from 12,122 in 2015 to 17,258 in 2016.* Psychostimulants with abuse potential include drugs such as methamphetamine, 3,4-methylenedioxy-methamphetamine (MDMA), dextroamphetamine, levoamphetamine, methylphenidate (Ritalin), and caffeine. From 2015 to 2016, cocaine-involved and psychostimulant-involved death rates increased 52.4% and 33.3%, respectively (1). A total of 70,237 persons died from drug overdoses in the United States in 2017; approximately two thirds of these deaths involved an opioid (2). CDC analyzed 2016-2017 changes in age-adjusted death rates involving cocaine and psychostimulants by demographic characteristics, urbanization levels, U.S. Census region, 34 states, and the District of Columbia (DC). CDC also examined trends in age-adjusted cocaine-involved and psychostimulant-involved death rates from 2003 to 2017 overall, as well as with and without co-involvement of opioids. Among all 2017 drug overdose deaths, 13,942 (19.8%) involved cocaine, and 10,333 (14.7%) involved psychostimulants. Death rates increased from 2016 to 2017 for both drug categories across demographic characteristics, urbanization levels, Census regions, and states. In 2017, opioids were involved in 72.7% and 50.4% of cocaine-involved and psychostimulant-involved overdoses, respectively, and the data suggest that increases in cocaine-involved overdose deaths from 2012 to 2017 were driven primarily by synthetic opioids. Conversely, increases in psychostimulant-involved deaths from 2010 to 2017 occurred largely independent of opioids, with increased co-involvement of synthetic opioids in recent years. Provisional data from 2018 indicate that deaths involving cocaine and psychostimulants are continuing to increase.† Increases in stimulant-involved deaths are part of a growing polysubstance landscape. Increased surveillance and evidence-based multisectoral prevention and response strategies are needed to address deaths involving cocaine and psychostimulants and opioids. Enhancing linkage to care, building state and local capacity, and public health/public safety collaborations are critical components of prevention efforts.