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Epidemiologic Perspective on Substance Use and Drug Overdose in Minnesota Key findings, novel insights, and innovative public health surveillance strategies
Epidemiologic Perspective on Substance Use and Drug Overdose in Minnesota:
Key findings, novel insights, and innovative public health surveillance strategies
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From 2000 through 2021, over 10,000 Minnesotans have died from a drug overdose.1 Furthermore, preliminary 2021 death data indicate that drug overdoses will surpass falls as the leading cause of injury mortality in Minnesota, highlighting the alarming rise in drug overdose deaths over the past two decades.2 Currently, the drug overdose epidemic is characterized by novel psychoactive substances, including synthetic opioids, psychostimulants, and benzodiazepines. Drug overdose deaths, however, are just the top of the injury pyramid. For every overdose death there were 11 nonfatal hospital-treated drug overdoses in 2020.3 This article highlights key findings and emerging trends in drug overdose deaths and nonfatal hospital-treated drug overdoses in Minnesota. This includes discussion of the limitations of current public health surveillance systems and improvements being undertaken to provide comprehensive and timely information to support prevention efforts around drug overdose and substance use in Minnesota.
Fatal Drug Overdose
Analysis of death certificate data has shown that the Minnesota drug overdose mortality rate increased by 34% from 2019 to 2020, rising from 14.2 to 19.0 per 100,000 population.1 The increase in drug overdose deaths is driven primarily by opioids, with about 60% of drug overdose deaths involving opioids.4 Much of the growth in opioid-involved overdose deaths can be attributed to synthetic opioids, which death scene investigation and toxicology results indicate are likely due to illicitly manufactured fentanyl.5,6 Opioids, however, are not the only substances of concern. All drug categories increased in 2020.5 Of particular concern are psychostimulants, which toxicology findings indicate are primarily methamphetamine. Psychostimulant-involved deaths have virtually paralleled the increase in synthetic opioid-involved deaths, with the number of psychostimulant-involved deaths nearly quadrupling in the past six years.7 Increases in drug overdose deaths over the past few years have also been characterized by polysubstance use. For example, from 2017 to 2019, nearly 50% of psychostimulant-involved deaths involved at least one opioid; 57% of cocaine-involved deaths involved at least one opioid; and 82% of benzodiazepine-involved deaths involved at least one opioid. Across each of these categories, the contribution of synthetic opioids has grown substantially from less than 10% in 2011 to 2013 to 33% or more of deaths in 2017 to 2019.8 Furthermore, over the past 10 years, 18% of opioid-involved deaths involved alcohol.9 Death certificates are a critical data source for public health surveillance, but there are important limitations. First, death certificates are not timely. It may take weeks for a death certificate to be finalized and made available for analysis. Second, death certificates lack detailed toxicology data, with 13% of drug overdose deaths lacking any information on specific drugs involved.1 Finally, death certificate data lack circumstantial information on the events leading up to and at the time of death that are crucial for prevention and response efforts. With support from the Centers for Disease Control and Prevention, we have implemented the State Unintentional Drug Overdose Reporting System (SUDORS) that provides comprehensive and timely information on drug overdose deaths. This system collects and abstracts data from death certificates and medical examiner/coroner reports, including scene findings, autopsy reports, and toxicology findings. The goals of SUDORS are to better understand the circumstances that surround overdose deaths; improve overdose data timeliness and accuracy; and identify specific substances causing or contributing to overdose deaths.10 SUDORS has shown that four out of five people who died of a drug overdose in Minnesota had an identified opportunity for intervention.11 This includes a recent release from institution (e.g., hospital or jail/prison), history of prior overdose, an
identified mental health problem, history of substance use treatment, evidence that a bystander was present, or the drug use was witnessed. Prevention, treatment, and response efforts that address these opportunities for intervention are supported by MDH, in partnership with local organizations and communities.
Nonfatal Drug Overdose
In 2020, for every one overdose death, there were 11 nonfatal hospital-treated overdoses.3 Emergency department (ED) visits for drug overdose continue to increase, rising 44% from 2016 to 2020 (5,079 to 7,290 overdoses). It should be noted that this does not include visits related to alcohol use, which is a cause of a significant number of hospital visits. Based on diagnosis codes, opioids or stimulants were involved in 57% of ED visits for nonfatal overdose. From 2016 to 2020, the number of nonfatal overdoses that involved all opioids more than doubled, from 1,501 to 3,804 overdoses; heroin and stimulant overdoses increased from 2016 to 2019 but remained relatively stable from 2019 to 2020. The interpretation of hospital data is also subject to important limitations. Drugs identified in nonfatal overdoses are often self-reported by the patient or determined by presenting symptoms at the hospital; toxicology testing is often not completed. Caution is thus required when interpreting the hospital data because of a lack of detail on specific substances involved. Effective and tailored prevention strategies for populations at risk rely on accurate identification of substances involved in these nonfatal events. To provide this information, MDH developed the Minnesota Drug Overdose and Substance Misuse Surveillance Activity (MNDOSA) to understand substance misuse and drug overdose patterns.12 MNDOSA illuminates the types of substances being used in Minnesota by conducting toxicology testing at MDH Public Health Laboratory for a subset of MNDOSA cases. These results inform clinicians, community partners, and the public about substance use trends to guide prevention and treatment efforts. MNDOSA results show that amphetamines were the most common substances detected. Furthermore, substances were often detected in samples more frequently than were suspected.13 After linking hospital discharge and MNDOSA data, most importantly, 68% of MNDOSA cases were not identified through traditional hospital-based surveillance of drug overdoses; this finding is consistent with previous epidemiologic investigations.14 This result highlights how traditional surveillance methods focusing on only drug overdoses are insufficient at describing hospital utilization for substance use. Fatal and nonfatal overdoses continue to rise, with unfortunate signs that the year-to-year increase has only grown over recent time. Opioids remain the primary driver, but we are also seeing significant increases in psychostimulant-involved deaths. However, our evolving public health surveillance systems that monitor drug overdose and substance use now collect more timely and comprehensive data. We have used these novel data to inform prevention, treatment, and response efforts in local communities, among first responders, and with harm reduction programs by identifying locations and populations with greater overdose burden. With drug overdoses expected to become the leading cause of injury mortality in Minnesota in 2021, better data and information can inform the work needed to change the course of the substance use and drug overdose epidemic.
Nate Wright, MPH, is the Epidemiologist Supervisor of the Drug Overdose Epidemiology Unit in the Injury and Violence Prevention Section at the Minnesota Department of Health. He is the surveillance coordinator for the Centers for Disease Control and Prevention funded Overdose Data to Action initiative and is the Principal Investigator for Minnesota’s Syndromic Surveillance System. He can be reached at: Email: nate.wright@ state.mn.us; Phone: 651-201-4237.
References available upon request.
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