Forensic Epidemiology: Monitoring Fatal Drug

Overdose Trends
The New Mexico Experience

Sarah Lathrop, DVM, PhD

Professor of Pathology UNM HSC
 Overview
• New Mexico and medicolegal death
investigation
• Assessing potential overdose deaths
• Trends in overdose deaths in New Mexico
• Special studies of opioid overdoses
• Partnerships and the importance of
collaboration
Getting to know New Mexico…
• 5th largest state geographically
• 2.1 million people as of 2018
• 49.1% Hispanic
• 10.9% American Indian
• 23 American Indian tribes
– 19 Pueblos
– Three Apache tribes
– Navajo Nation
New Mexico Office of the Medical
Investigator
• Centralized, statewide
medical examiner agency
• Investigates all deaths which
are untimely, suspicious,
violent or unattended by a
physician
• 8 board-certified FPs
• 2,000 autopsies per year
 OMI Standard Operating Guidelines
• Potential drug related deaths brought to office
– Based on history and scene investigation

• PMCT performed to rule out trauma, identify

natural disease, check for overdose findings
(cerebral edema, pulmonary edema, dilated
bladder)
 OMI Standard Operating Guidelines
• Use urine drug screen to triage cases accordingly
• Confirmatory tox testing by NMS Labs
• Cases fall into 1 of 5 categories
– Young and healthy (UDS + external; UDS – autopsy)
– Significant natural disease (external exam and UDS)
– Lethal disease (use UDS to determine if tox testing
needed)
– Acute vs chronic ethanol (external exam and tox testing)
– Suicidal or other exposures (full autopsy)
 Drug Overdose Death Rates
New Mexico and United States, 1990-2018
30
26.6
Deaths per 100,000 persons

25

20 21.7
15
7.7
10
New Mexico
5
United States
3.4
0
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
Year
Rates are age adjusted to the US 2000 standard population
Source: United States (CDC Wonder); New Mexico (NMDOH BVRHS/SAES, 1990-1998,2016-2018 ; NM-IBIS, 1999-2015)
Courtesy Jim Davis NMDOH
 Overdose Death Involvement Rates by Drug
14
Class, NM, 2012-2018
Non-fentanyl Rx…
12
Deaths per 100,000 population

Methamphetamine
10

8
Heroin
Benzodiazepines
6

4 Alcohol
Fentanyl &…
2

0
2012 2013 2014 2015 2016 2017 2018

Drug categories are not mutually exclusive - many deaths involve more than one class
Rates are age adjusted to the US 2000 standard population
Source: NM DOH Bureau of Vital Records and Health Statistics death data Courtesy Jim Davis NMDOH
 Deaths per 100,000 population

10
20
30
40
50
60
70
80
90

0
100
Rio Arriba 92.8
San Miguel 47.1
Hidalgo 46.9
Lincoln 42.0
Grant 40.3
Catron 38.0
Guadalupe 36.6
Colfax 36.1
Sierra 35.7

Courtesy Jim Davis NMDOH population estimates

De Baca 34.9
Taos 31.9

Rates are age adjusted to the US 2000 standard population

Santa Fe 31.4
Torrance 31.0
Valencia 29.2
Eddy 28.2
Bernalillo 27.3
Luna 23.1
2018

Quay 22.8

Source: NM DOH Bureau of Vital Records and Health Statistics death data; UNM/GPS
Sandoval 20.8
Chaves 20.7
Otero 20.6
Los Alamos 20.3
Socorro 20.0
Curry 18.5
Lea 18.3
Cibola 18.3
Dona Ana 17.7
San Juan 17.4
Mora 13.7
McKinley 13.6
Roosevelt 10.6
Union 5.0
Harding
New Mexico 25.5
Drug Overdose Death Rate by County, NM, 2014-
 Opioid Overdose Death Rates by Age, Sex and
Drug Type, NM 2014-2018
25
Rx Opioid only Heroin Only Rx Opioid & Heroin
Deaths per 100,000 population

20

15

10

0
15-24
25-34
35-44
45-54
55-64
65-74
75-84

15-24
25-34
35-44
45-54
55-64
65-74
75-84
85+

85+
0-4

0-4
5-14

5-14
Male Female
NMDOH Bureau of Vital Records and Health Statistics death data, UNM/GPS population estimates Courtesy Jim Davis NMDOH
 Ongoing epidemiologic research
• Scene findings associated with unintentional
overdose deaths by age

• Unintentional overdose deaths among women

• NIJ-funded comparison of autopsy and PMCT

findings: toxicology cohort
 Comparing prescription overdose deaths
in decedents 50 or older to those under 50
Prescription overdose Prescription
Risk factors % %
<50 overdose>50
Evidence of scene
15 7 9 9.2
scrubbing
Multiple
26 12.1 11 11.2
drugs/paraphernalia
Alcohol-related
65 30.2 27 27.6
elements at scene
History of depression* 96 44.7 35 35.7
Released from jail w/in
4 1.9 2 2
past month
History of disease* 59 29.7 64 65.3
Total 215 98

Dubois T, Andrews S, Lathrop S. Death scene finding associated with accidental toxicity in New Mexico
(2010-11) AAFS Annual Meeting Feb 2015
 2011-2015 New Mexican Female Unintentional Overdose Deaths
Primary Drugs Listed in Cause of Death Statement A

50
Percent Deaths with Specific Drugs Listed in

43.8

37.5
COD Statement A

25 23.3

16.4 15.5 15.5

11.7 10.1
12.5 9.6
7.6
4.9
2.7 2.7 1.1
0

Primary Drugs Listed in COD Statement A

Gandara E et al, “Accidental overdose deaths in women: Toxicological trends in NM from 2011-2015,” NM Women’s
Health Conference Feb 2019
Comparison of cause of death statements, under and
over 40 overdose decedents

Cause of death, Under 40, 40 and older,

DC DC Review Neither
comparing DC to match & % % match & % % % %
correct correct correct correct
review correct correct

Part 1

0.0
Line 1 97/113 85.8 16/16 100 259/344 75.3 82/85 2/85 1/85 1

Line 2 1/1 100 12/37 24/25 1/25

Line 3 NA 5/8 3/3 100

Line 4 NA NA

Lathrop S and Nolte K, Utility of postmortem x-ray CT in supplanting or supplementing

medicolegal autopsies, Final Technical Report, NIJ Award 2010-DN-BX-K205
 Collaboration!
• Key to informing prevention and control
measures
• Get to know your local health department and
DEA/HIDTA office
• Local School of Public Health
• Check with legal counsel to determine how much
data/PHI can share
• Timeliness can be a challenge
 Summary: The New Mexico
Experience
• Decades of high rates of unintentional overdose
deaths
• Triage system in place using PMCT, UDS
• Epidemiologist provides baseline surveillance,
data requests and special studies
• Partnerships with other agencies key to
maximizing utility of overdose investigation data
New Mexico data

Annual Reports
2000-2018:
https://omi.unm.edu/repo
rts/index.html