Mandatory Reporting of Fatal and Nonfatal Opioid Overdoses in a Rural Public Health Department

Abstract

In 2016, Clallam County became the first county in Washington State to mandate reporting of fatal and nonfatal opioid overdoses. This reporting improved our understanding of opioid overdoses in the community and allowed us to provide harm reduction and case management services after nonfatal overdoses. By using the Washington State Prescription Monitoring Program, we have been able to notify health care providers when their patients have experienced a fatal or nonfatal opioid overdose to help better guide their prescribing practices.

Clallam County has one of the highest rates of opioid-overdose deaths and hospitalizations in Washington State.^1,2 Washington State law allows local health officers to add conditions of public health significance to the list of mandatory notifiable conditions.

INTERVENTION

As part of a comprehensive response to the opioid crisis in our community, Clallam County developed a program to require timely reporting of fatal and nonfatal opioid overdoses. The goal was to leverage the existing public health reporting system to address a noncommunicable disease crisis in our community.

PLACE AND TIME

Clallam County is a geographically large, rural county with approximately 75 000 residents, located in northwestern Washington State. It has a land area of 1740 square miles with roughly half designated as wilderness in Olympic National Park and Olympic National Forest. During 2012 to 2016, Clallam County had the second-highest opioid-associated death rate in Washington State, 14.5 per 100 000.¹ After a public hearing and approval by our local board of health, fatal and nonfatal opioid overdose was added to our list of notifiable conditions late in 2015, and reporting began on January 1, 2016.

PERSON

Mandatory reporting identified patients who were treated in either of the two emergency departments in Clallam County for either fatal or nonfatal opioid overdoses. The county coroner reported opioid-associated deaths that occurred outside the hospital system.

PURPOSE

The purpose of the program was to improve the quality and timeliness of data about the geographic and demographic distribution of opioid overdoses in the community and to identify high-risk patients who might benefit from direct services to reduce the risk of mortality, morbidity, and outbreaks of communicable diseases associated with opioid use. These direct services included naloxone distribution, chemical dependency and mental health referrals, syringe exchange services, and hepatitis C testing. We also wanted to provide feedback to providers when overdoses involved prescribed opioids because of evidence in other settings that approximately 90% of patients continue to receive prescribed opioids even after a nonfatal overdose³ and to help prescribers identify patients in their practice who are at high risk of future overdose events. The program was also designed to facilitate detection and investigation of clusters of overdoses that may be attributable to unexpected or high-potency opioids circulating in the community.

IMPLEMENTATION

Before implementing the mandatory reporting requirement, Clallam County Health and Human Services (CCHHS) met with the leaders of our hospital emergency departments, emergency medical services systems, and the coroner’s office to build community consensus on the need for this new reporting requirement. After starting the program, we met regularly with the relevant organizations to streamline reporting and review compliance.

Emergency departments were asked to report fatal and nonfatal opioid overdose patients by name to CCHHS within 24 hours of patient contact. The county coroner reported opioid-associated deaths to CCHHS when deaths occurred outside the hospital system. A public health nurse reviewed reports daily and made attempts to contact the patient after nonfatal overdoses. Once patients were contacted they were invited to our syringe exchange program and offered naloxone. Patients were also referred to a chemical dependency professional who attempted to contact the patient to offer inpatient treatment or medication-assisted outpatient treatment. The Clallam County Board of Health provided ethics oversight for the program.

At the beginning of the program, we developed a standard notification letter that was sent to the patient’s provider if the patient or hospital EMR reported use of prescription opioids. In July 2017, the law regulating the Washington State Prescription Monitoring Program, a statewide electronic database of dispensing records for scheduled drugs by prescribers, changed to allow health officers to access the Prescription Monitoring Program after all fatal and nonfatal opioid overdoses. This allowed us to identify and subsequently notify any providers who had prescribed controlled substances to the patient in the past year.

We also provided feedback to the community through a quarterly opioid surveillance report that presented the demographics and geographic distribution of overdose cases and other metrics associated with opioid use in the community.

EVALUATION

We received 13 fatal and 80 nonfatal overdose reports (total 93) involving 85 different patients from January 1, 2016, through December 31, 2017, for an average annual overdose rate of 63.0 per 100 000. Six individuals had multiple nonfatal overdoses. Five patients had two overdoses during the two-year period and one had four overdoses. We received an average of 12 reports each quarter (range = 6–20). The number of reports declined statistically significantly over time (JoinPoint Regression Program version 4.5.0.1, National Cancer Institute, Rockville, MD).

The program was effective at reaching patients after nonfatal overdoses and providing them direct services (Table 1). Unfortunately we did not have enough funding to conduct long-term follow-up of these patients to see how many of them successfully initiated and sustained treatment.

TABLE 1—

Characteristics of Opioid Overdose Cases Reported to Clallam County Health and Human Services (CCHHS): Washington State, 2016–2017

	2016, No./Total No. (%)	2017, No./Total No. (%)	2016–2017, No./Total No. (%)
Total opioid overdose reports received	62	31	93
Source of reports
Report submitted by emergency departments	56/62 (90)	26/31 (84)	82/93 (88)
Report submitted by coroner	6/62 (10)	5/31 (16)	11/93 (12)
Case characteristics
Cases by age group, y
0–17	2/62 (3)	0/31 (0)	2/93 (2)
18–29	22/62 (35)	9/31 (29)	31/93 (33)
30–39	12/62 (19)	12/31 (39)	24/93 (26)
40–49	10/62 (16)	4/31 (13)	14/93 (15)
50–59	9/62 (15)	5/31 (16)	14/93 (15)
≥ 60	7/62 (11)	1/31 (3)	8/93 (9)
Cases by gender
Male	42/62 (68)	19/31 (61)	61/93 (66)
Female	20/62 (32)	12/31 (39)	32/93 (34)
Cases already participating in CCHHS syringe exchange	24/62 (39)	12/31 (39)	36/93 (39)
Cases who had received a naloxone kit of all cases already participating in CCHHS syringe exchange	12/24 (50)	7/12 (58)	19/36 (53)
Opioid overdose characteristicsa
Overdose involved heroin as main opioid	43/62 (69)	22/31 (71)	65/93 (70)
Overdose involved prescription opioid as main opioid	18/62 (29)	6/31 (19)	23/93 (25)
Fatal overdose	6/62 (10)	7/31 (23)	13/93 (14)
Services
Nonfatal cases with person-to-person contact with public health	46/56 (82)	14/24 (58)	60/80 (75)
Nonfatal cases with person-to-person contact with public health who received naloxoneb	23/45 (51)	11/14 (79)	34/59 (58)
Nonfatal cases with person-to-person contact who were referred by public health to a chemical dependency professional	43/45 (96)	14/14 (100)	57/59 (97)

Note. Each case represents a single overdose event. There were 58 unique patients in 2016 and 31 in 2017.

^aThe opioid involved was unknown in four cases (one in 2016, three in 2017).

^bDenominator excludes one case, an unintentional overdose by a child.

The program was also successful at increasing our understanding of opioid overdoses in the community (Table 1). The majority of overdoses were among men (66%) and attributable to heroin (71%). Using 95% confidence intervals, no case characteristics were statistically different from 2016 to 2017. The highest overdose rates occurred in regions of the county with a younger population⁴ and higher rates of poverty⁵ (data not shown).

Although reported overdose rates have declined over the past two years, we are unable to attribute the trend to this program. Although our emergency medical services providers consistently attempt to transport patients with nonfatal overdoses to our emergency departments, and our emergency departments are consistent and willing reporters, anecdotally, the successful distribution of naloxone in the community by our syringe exchange program (with routine refills after use) means that many nonfatal overdoses are being managed by friends and family without interaction with the medical system. In addition, our community has rapidly expanded access to medication-assisted treatment, including in our jail, and has prioritized treatment of high-risk patients through partnerships with law enforcement and mental health providers.

ADVERSE EFFECTS

There were no adverse consequences to patients. Although we did not systematically track feedback from patients and their families, we found almost universal support for the program after they were contacted and offered services. Direct patient follow-up after an opioid overdose was often challenging and required multiple attempts utilizing phone and social media because of unstable living situations and unreliable phone access. Like many small health departments with limited funding, using resources to address opioid overdoses shifted resources from other important public health work.

SUSTAINABILITY

In Clallam County, opioid-use disorder is an important public health and safety issue. Substance use was identified as a top priority in our Community Health Improvement Plans in 2013 and again in 2017. Ideally, the coordination of comprehensive treatment of opioid-use disorders, including naloxone distribution after nonfatal overdoses, notification of providers, and case management for linking high-risk patients to treatment, would be provided inside the health care delivery system. Until those services are available in our medical system, our public health system will continue to support this work with local funding and grants and by supplanting other, lower-priority work.

PUBLIC HEALTH SIGNIFICANCE

Local reporting of opioid overdoses to the public health system allows both patient-level intervention and surveillance for a clinical condition of public health significance. Our future goals include automating the reporting for opioid overdoses through real-time analysis of emergency department billing data and partnering with our hospital systems to distribute naloxone and initiate medication-assisted treatment before hospital discharge.