Drug Poisoning Deaths Involving Heroin St. Louis County, Missouri Drug poisoning (overdose) is the number one cause of injury related death in the ited States. 1 While the rate for deaths involving opioid analgesics (prescription pain medication) has leveled in recent years, the rate for deaths involving heroin has been steadily increasing since 2010. 1,2 The greatest increase has been seen in the Midwest heroin death rates have increased from 0.7 per 100,000 population in 2007 to 4.3 per 100,000 in 2013. 1 Using data from the Missouri Department of Health and Senior Services, Bureau of Vital Statistics, this data report provides a description of trends and demographics for heroin related drug poisoning deaths in St. Louis County, Missouri from 2010 through 2014. Figure 1. Age adjusted rates for drug poisoning deaths involving heroin: St. Louis County, Midwest, and ited States, 2010 2014. 16.0 14.0 Deaths per 100,000 Population 12.0 10.0 8.0 6.0 4.0 2.0 0.0 St. Louis County Midwest (Year 2013 value) ited States 2010 2011 2012 2013 2014 Year Sources: Missouri Department of Health and Senior Services, Bureau of Vital Statistics and the Centers for Disease Control and Prevention, National Center for Health Statistics. Figure 1 shows heroin death rates, described as drug poisoning deaths involving heroin, that have been adjusted for differences in age distribution between populations (i.e., age adjusted) for St. Louis County, the Midwest for 2013 (the highest rate recorded in recent years), and the ited States through 2013. The error bars shown in the figure for St. Louis County (i.e., the vertical lines intersecting each point) are a graphical representation of the 95% confidence intervals (CI) for each death rate. As seen in 2013, the St. Louis County rate of drug poisoning deaths involving heroin were over 3.7 times the national average 10.0 per 100,000 population (88 total deaths of St. Louis County residents) as compared to 2.7 per 100,000 for the ited States overall. In 2014, the rate increased to 12.2 per 100,000 in St. Louis County with a total of 110 deaths involving heroin. Note: This report includes all heroin deaths of St. Louis County residents that occur within or outside of St. Louis County s boundary.
Drug poisoning Deaths Involving Heroin Page 2 of 13 Table 1. Drug poisoning deaths involving heroin per 100,000 population, St. Louis County, 2010 2014 average. Rate 95% Confidence Interval Count per Year St. Louis County 9.7 8.8 to 10.6 88 Age Group < 18 years 0.7* 0.3 to 1.3 1 18 24 years 12.3 9.2 to 15.8 11 25 44 years 22.5 19.9 to 25.2 55 45 64 years 7.3 6.0 to 8.8 21 65 years and over 0.4 0.1 to 0.9 1 Sex Male 15.4 13.8 to 17.2 68 Female 4.4 3.6 to 5.3 21 Race/Ethnicity Asian 0.0 0.0 to 0.0 0 Black/African American 10.0 8.2 to 12.1 22 Hispanic or Latino 1.6* 0.1 to 6.6 < 1 Multiple 2.8* 0.4 to 8.6 1 White 10.7 9.5 to 11.9 65 Neighborhood Poverty Very High 13.4 9.1 to 18.7 7 High 14.9 11.8 to 18.6 16 Medium 11.3 9.3 to 13.4 26 Low 7.8 6.8 to 9.0 40 Geographic Area Central 5.1 3.5 to 7.1 7 Inner North 16.7 14.0 to 19.6 29 Outer North 7.5 6.0 to 9.3 17 South 13.2 10.8 to 15.8 23 West 5.0 3.8 to 6.4 12 Comparisons: Higher than St. Louis County rate Lower than St. Louis County rate Notes: Source: Missouri Department of Health and Senior Services (MoDHSS), Bureau of Vital Statistics. Case Definition: International Classification of Diseases, 10th Revision (ICD 10) multiple cause code T40.1. Rates are age adjusted to the 2000 US population (not including Age Group rates). *Too few cases to meet precision standard (relative standard error <30%); interpret with caution. Table 1 describes the 5 year rates for Saint Louis County drug poisoning deaths involving heroin by important demographics age adjusted. The count per year is the average number of deaths per year from heroin. Rates were greatest for individuals that were aged 25 to 44, male, living in areas of high poverty, and living in the inner north or south regions of the county. Heroin overdose deaths in those aged 25 to 44 years were more than 2 times likely than any other age group. The lowest rates geographically occurred in the central and west regions of the county while the inner north and south regions are more than twice as likely to die from a heroin overdose. The 5 year rate showed no difference between Black/African Americans or White residents.
Drug poisoning Deaths Involving Heroin Page 3 of 13 Figure 2. Age adjusted rates for drug poisoning deaths involving heroin by gender, St. Louis County, 2010 2014. 30.0 25.0 Deaths per 100,000 Population 20.0 15.0 10.0 5.0 Males Females 0.0 2010 2011 2012 2013 2014 Year Source: Missouri Department of Health and Senior Services, Bureau of Vital Statistics. Note: Error bars ( I ) represent the 95% confidence interval. A greater increase in deaths due to heroin has been occurring in males for the past two years. In 2013, heroin deaths in males were 3.9 times greater compared to females (16.1 versus 4.1 per 100,000 population) and in 2014, were 4.2 times greater compared to females (20.2 versus 4.8, respectively).
Drug poisoning Deaths Involving Heroin Page 4 of 13 Figure 3. Rates for drug poisoning deaths involving heroin by selected age groups, St. Louis County, 2010 2014. Deaths per 100,000 Population 40.0 35.0 30.0 25.0 20.0 15.0 10.0 5.0 0.0 2010 2011 2012 2013 2014 Year Source: Missouri Department of Health and Senior Services, Bureau of Vital Statistics. Note: Error bars ( I ) represent the 95% confidence interval. 18 24 25 44 45 64 Although all age groups have seen an increase in 2014 compared to 2013, a large gap is seen in those 25 to 44 years of age compared to the 18 to 24 and 45 to 64 age groups (26.9 aged 25 to 44 compared to 15.8 aged 18 to 24 and 9.3 per 100,000 population aged 45 to 64 years, respectively). Figure 4. Age adjusted rates for drug poisoning deaths involving heroin by selected race groups, St. Louis County, 2010 2014. Deaths per 100,000 Population 25.0 20.0 15.0 10.0 5.0 0.0 2010 2011 2012 2013 2014 Year Source: Missouri Department of Health and Senior Services, Bureau of Vital Statistics. Note: Error bars ( I ) represent the 95% confidence interval. Black/African American White No large disparities between Black/African American and White St. Louis County residents are observed.
Drug poisoning Deaths Involving Heroin Page 5 of 13 Figure 5. Age adjusted rates for drug poisoning deaths involving heroin by geographic area, St. Louis County, 2010, 2012, and 2014. 30.0 25.0 2010 2012 2014 Deaths per 100,000 Population 20.0 15.0 10.0 5.0 0.0 Central Inner North Outer North South West Geographic Area Source: Missouri Department of Health and Senior Services, Bureau of Vital Statistics. Note: Error bars ( I ) represent the 95% confidence interval. Three regions have seen an increase all three years: central (2.2 per 100,000 population in 2010 vs. 6.0 in 2012 vs. 8.4 in 2014), inner north (12.7 per 100,000 population in 2010 vs. 17.0 in 2012 vs 18.0 in 2014) and outer north (3.9 per 100,000 population in 2010 vs. 6.1 in 2012 vs. 10.3 in 2014), respectively. The south region nearly doubled its rate from 2012 in 2014 (8.6 per 100,000 population in 2012 versus 15.1 in 2014, respectively).
Drug poisoning Deaths Involving Heroin Page 6 of 13 Map 1. Drug poisoning deaths involving heroin per 100,000 population by ZIP code, St. Louis County, 2010 2014. Age-Adjusted Heroin-Related Death Rate per 100,000 Population stable Rate (Interpret with Caution) 63034 0.0 < 5.0 5.0 9.9 10.0 19.9 20.0 29.9 30.0 Zip Codes populated UN 364 63146 63045 63043 63044 63031 63042 63134 63074 63114 63033 63135 63136 63121 Uq 63137 63138!"e$ 63005 63141 63017!"e$ 63131 63011 U U 63122 63038 63040 63021 63133 63132 63130 63105 63124!"e$ 63117 63144 63119 City of St. Louis!"e$ Iz 63088 63126 63123 Iz Iz 63127 63026 63069 63025 63125 63049 Iz 63128 Iz %&j(. 0 2 4 8 Miles 63129 Data Source: Missouri Department of Health and Senior Services, Bureau of Vital Statistics The map shows the distribution of heroin deaths based upon the residence of an individual at the time of death. A greater concentration is seen in the more northern region of the county along Interstate 70.
Drug poisoning Deaths Involving Heroin Page 7 of 13 Map 2. Drug poisoning deaths involving heroin by geographic area comparison, St. Louis County, 2010 2014. Age-Adjusted Heroin Death Rate Comparison Higher than St. Louis County rate Lower than St. Louis County rate Not signficantly different than St. Louis County rate Geographic Areas populated Outer North Uq Inner North UN 364!"e$ West!"e$ U!"e$ Central City of St. Louis!"e$ Iz U Iz Iz Iz Iz South %&j(. 0 2 4 8 Miles Data Source: Missouri Department of Health and Senior Services, Bureau of Vital Statistics The inner north and south regions have a significantly higher rate than the overall St. Louis County rate for mortality from heroin. The central and west regions have a significantly lower heroin mortality rate while the outer north region does not experience a rate significantly different from the overall county.
Drug poisoning Deaths Involving Heroin Page 8 of 13 Map 3. Drug poisoning deaths involving heroin by ZIP code comparison, St. Louis County, 2010 2014. Age-Adjusted Heroin Death Rate Comparison Higher than St. Louis County rate Lower than St. Louis County rate Not signficantly different than St. Louis County rate 63034 Zip Codes populated 63042 63031 63033 Uq 63138 63045 63044 63134 63135 63136 63137 UN 364 63146 63043 63074 63114 63121!"e$ 63005 63141 63017!"e$ 63131 63011 U U 63122 63038 63040 63021 63133 63132 63130 63105 63124!"e$ 63117 63144 63119 City of St. Louis!"e$ Iz 63088 63126 63123 Iz Iz 63127 63026 63069 63025 63125 63049 Iz 63128 Iz %&j(. 0 2 4 8 Miles 63129 Data Source: Missouri Department of Health and Senior Services, Bureau of Vital Statistics This map shows the zip codes where the rates are higher than the overall county rate. The majority of the areas are in the north and south regions of the county.
Drug poisoning Deaths Involving Heroin Page 9 of 13 Map 4. Drug poisoning deaths involving heroin by ZIP code comparison using the Midwest rate for 2013, Age-Adjusted Heroin Death Rate Comparison Higher than Midwest 2013 rate Lower than Midwest 2013 rate Not signficantly different than Midwest 2013 rate 63034 Zip Codes populated 63042 63031 63033 Uq 63138 63045 63044 63134 63135 63136 63137 UN 364 63146 63043 63074 63114 63121!"e$ 63005 63141 63017!"e$ 63131 63011 U U 63122 63038 63040 63021 63133 63132 63130 63105 63124!"e$ 63117 63144 63119 City of St. Louis!"e$ Iz 63088 63126 63123 Iz Iz 63127 63026 63069 63025 63125 63049 Iz 63128 Iz %&j(. 0 2 4 8 Miles 63129 Data Source: Missouri Department of Health and Senior Services, Bureau of Vital Statistics This map shows the zip codes that are higher and lower than the Midwest rate for 2013. More than three quarters of the county zip codes had higher than the Midwest rate for mortality from heroin.
Drug poisoning Deaths Involving Heroin Page 10 of 13 Methods Data was obtained from the Missouri Department of Health and Senior Services, Bureau of Vital Statistics for the years 2010 to 2014. Cases of drug poisoning deaths involving heroin were identified using the International Classification of Diseases, Tenth Revision (ICD 10) underlying cause code T40.1 or the combination of the underlying poisoning codes X40 X44 (unintentional), X60 X64 (suicide), X85 (homicide), or Y10 Y14 (undetermined intent) and multiple cause code T40.1. The data received captures all heroin deaths of St. Louis County residents (within or outside of St. Louis County). The American Community Survey (ACS) was used to generate 1 year estimates for the St. Louis County population by age, gender, and race for 2010 2014. The percent of residents living below the federal poverty level for each census tract was also obtained from ACS using the 5 year estimate for 2009 to 2013. In the analysis, neighborhood poverty level was assigned to each death based on residence within each St. Louis County 2010 census tract. Each census tract was assigned one of four categories of percent below federal poverty level 3 : Low (0 to < 10 percent); Medium (10 to <20 percent); High (20 to <30 percent); and Very high (30 to 100 percent). Age adjusted and age specific rates and 95% confidence intervals were calculated in Microsoft Excel using population estimates from ACS. The rates were ageadjusted to the 2000 U.S. population 4. Geographic regions were determined from St. Louis County Planning division region maps by assigning each census tract a matching region. Maps were generated using ArcGIS for the vital statistics data for rates by zip code, and geographic regions. St. Louis County Action Plan The Saint Louis County Department of Public Health (DPH) and its partners are working to decrease the rate of drug poisoning deaths involving heroin using several strategies and key partnerships. 1. DPH has worked with a variety of data sources to develop a heroin profile including maps and tables that detail the scope and impact of heroin deaths in the community. It has also begun exploring additional avenues of data collection, including overdose information from hospitals and ambulance services. 2. The Narcan Partnership with the Saint Louis County Police will allow county officers to carry and administer Narcan to individuals who have overdosed from heroin upon arrival. Narcan (or naloxone) is an opiate antidote that blocks the effects of opioids, including heroin and prescription pain pills such as morphine, oxycodone, and Vicodin in effect reversing the overdose. DPH will continue to support the police use of this tool to stop overdose deaths. 3. For over 3 years, DPH has participated in awareness and education activities in the community, giving presentations and providing literature and resources, and identifying referral sources for available treatments. DPH makes referrals to programs such as the Behavioral Health Response Crisis Hotline, the National Council on Alcoholism and Drug Abuse (NCADA), and local hospital substance abuse programs. DPH regularly disseminates information to the public about the availability of high quality programs. 4. DPH has been a participant in distributing information about and supporting Prescription Drug Take Back events, and publishing information about other opportunities to dispose of medicine safely at police stations.
Drug poisoning Deaths Involving Heroin Page 11 of 13 5. DPH is in support of a Prescription Drug Monitoring Program to help prescribers identify patients that may be seeking opiates for abuse. 6. DPH also advocates for prescriber guidelines that promote patient safety and informed, sensible prescribing practices whenever opioids are prescribed since problematic practices are a leading contributor to the epidemic. 5 DPH has also disseminated the Missouri Hospital Association s Opiate Prescriber Guidelines. 7. DPH participates in several community partnerships, including Community Resources ited to Stop Heroin (CRUSH), in order to promote collaboration that matches the scale of this issue. These also provide many opportunities for intervention, the sharing of resources and information, and the ability to spread the message about best practices. These partnerships include city and county police, NCADA, schools, pharmacies, the State of Missouri, city and county health departments, treatment providers, and community organizations. With leadership from the County Police Department, CRUSH has already conducted several mass communication awareness campaigns and members are participating in school health curriculum classes across the county. 8. DPH has begun to research and recommend a syringe exchange program to not only reduce heroin deaths by providing an additional point of entry to care, but also to prevent the spread of Hepatitis C and HIV/AIDS, which have substantial potential to spread via intravenous drug use. Individuals addicted to prescription opioid painkillers are forty times more likely to become addicted to heroin 6. Opiate and heroin usage has become a key issue for St. Louis County which is now engaged in wideranging and multi disciplinary collaborations to enact policy, system, and environmental changes that can have a positive impact on both residents and the region. These initiatives are expected to expand and grow as long as the problem remains. Community Resources If you or someone you know is struggling with opioid or heroin abuse please contact any of the following resources in Saint Louis County: Behavioral Health Response 24/7 Crisis Hotline: 800 811 4760 SSM Behavioral Health Services, Central Intake/Assessment and Referral Center: 800 426 2083 Bridgeway Behavioral Health: 866 758 1152 MO Community Mental Health Liaison: 800 811 4760 Provident Life Crisis Services 24/7 Hotline: 800 273 8255 Narcotics Anonymous 24/7 Helpline: 314 830 3232 National Council on Alcoholism and Drug Abuse: 314 962 3456 BJC Behavioral Health (St. Louis County Residents): 314 729 4004 (Day); 314 469 6644 (Night) Preferred Family Healthcare: 636 946 6376 (Day); 800 964 7118 (Night) References 1. Hedegaard, H., L.H. Chen, and M. Warner, Drug poisoning Deaths Involving Heroin: ited States, 2000 2013. NCHS Data Brief, 2015(190): p. 1 8.
Drug poisoning Deaths Involving Heroin Page 12 of 13 2. Rudd, R.A., et al., Increases in heroin overdose deaths 28 States, 2010 to 2012. MMWR Morb Mortal Wkly Rep, 2014. 63(39): p. 849 54. 3. Toprani A, Hadler JL. Selecting and applying a standard area based socioeconomic status measure for public health data: Analysis for New York City. New York City DOHMH: Epi Research Report, May 2013. 4. Klein RJ, Schoenborn CA. Age adjustment using the 2000 projected U.S. population. Healthy People Statistical Notes, no. 20. Hyattsville, Maryland: National Center for Health Statistics. January 2001. 5. Centers for Disease Control and Prevention. Injury Prevention & Control: Prescription Drug Overdose. http://www.cdc.gov/drugoverdose. May 2015. 6. Office of the Associate Director for Communications (OADC), Centers for Disease Control and Prevention. Today s heroin epidemic. http://www.cdc.gov/vitalsigns/heroin/index.html. July 2015. Suggested citation DeClue R, Dalidowitz L. Drug Poisoning Deaths Involving Heroin, St. Louis County Missouri. Chronic Disease Epidemiology (CDE) program profile, no 1. St. Louis County, MO: Department of Public Health. February 2016.
Drug poisoning Deaths Involving Heroin Page 13 of 13 Appendix: Individual Years Appendix. Drug poisoning deaths involving heroin per 100,000 population, St. Louis County, 2010 2014. 2010 2011 2012 2013 2014 Rate 95% CI Count Rate 95% CI Count Rate 95% CI Count Rate 95% CI Count Rate 95% CI Count St. Louis County 7.9 6.1 to 9.9 71 10.2 8.2 to 12.4 95 8.4 6.6 to 10.5 78 9.8 7.8 to 12.1 87 12.2 10.0 to 14.6 110 Age Group < 18 years 0.0 0.0 to 0.0 0 0.4* 0.0 to 1.0 1 0.0 0.0 to 0.0 0 0.4* 0.0 to 1.6 1 1.3* 0.3 to 3.2 3 18 24 years 10.4* 4.8 to 18.2 9 20.8 12.3 to 31.4 18 7.9* 3.2 to 14.8 7 6.7* 2.5 to 13.1 6 15.8 8.6 to 25.1 14 25 44 years 20.9 15.5 to 27.0 51 19.6 14.5 to 25.5 48 20.0 14.8 to 26.0 49 25.0 19.1 to 31.6 61 26.9 20.8 to 33.8 66 45 64 years 3.9 1.9 to 6.4 11 9.8 6.5 to 13.7 28 7.1 4.3 to 10.5 20 6.8 4.1 to 10.1 19 9.3 6.1 to 13.2 26 65 years and over 0.0 0.0 to 0.0 0 0.0 0.0 to 0.0 0 1.3* 0.2 to 3.5 2 0.0 0.0 to 0.0 0 0.6* 0.0 to 2.2 1 Gender Male 12.2 9.1 to 15.9 54 14.9 11.4 to 18.9 67 14.1 10.7 to 17.8 62 16.1 12.4 to 20.4 68 20.2 16.0 to 24.8 87 Female 3.8 2.2 to 5.8 17 5.9 3.9 to 8.3 28 3.3 1.9 to 5.3 16 4.1 2.4 to 6.0 19 4.8 3.0 to 7.2 23 Race Black/African American 6.4 3.4 to 10.0 14 9.0 5.5 to 13.7 21 10.5 6.4 to 15.0 23 10.7 6.7 to 15.9 23 13.6 9.2 to 19.4 30 White 9.5 7.1 to 12.3 57 11.7 9.1 to 14.7 73 8.5 6.3 to 11.0 53 10.7 8.1 to 13.6 63 13.3 10.4 to 16.5 79 Neighborhood Poverty Very High 12.1 4.0 to 26.5 6 to 13.5* 5.1 to 25.2 7 15.5* 5.7 to 28.3 7 16.4* 6.6 to 31.2 8 High 10.8* 5.2 to 17.8 11 17.3 10.2 to 25.7 19 16.2 8.8 to 24.7 16 14.3 7.9 to 22.5 15 16.2 9.3 to 25.2 18 Medium 8.2 4.8 to 12.2 19 12.5 8.2 to 17.4 29 9.9 6.2 to 14.5 23 8.6 5.9 to 14.1 23 15.8 10.9 to 21.8 36 Low 7.1 4.9 to 9.6 35 8.3 5.9 to 11.1 42 6.1 4.1 to 8.6 32 8.4 6.0 to 11.3 42 9.3 6.8 to 12.3 48 Geographic Area Central 2.2* 0.3 to 6.2 3 2.0* 0.3 to 5.9 3 6.0* 2.6 to 11.4 9 7.2* 3.1 to 13.3 9 8.4* 4.0 to 15.0 11 Inner North 12.7 7.7 to 19.0 22 18.5 12.6 to 25.7 34 17.0 11.1 to 24.5 28 17.2 11.4 to 24.5 29 18.0 12.1 to 25.3 32 Outer North 3.9* 1.6 to 7.3 9 9.0 5.5 to 13.6 21 6.1 3.3 to 10.2 14 8.3 4.9 to 12.9 19 10.3 6.5 to 15.4 23 South 11.0 6.5 to 17.0 19 18.2 12.1 to 25.8 30 8.6 4.8 to 13.7 16 12.9 8.0 to 19.4 22 15.1 9.7 to 21.9 27 West 7.8 4.5 to 12.2 18 2.7* 1.0 to 5.4 7 4.4* 2.1 to 7.7 11 3.3* 1.3 to 6.4 8 7.0 4.0 to 11.0 17 Comparisons: Higher than St. Louis County rate Lower than St. Louis County rate Notes: Source: Missouri Department of Health and Senior Services (MoDHSS), Bureau of Vital Statistics. Case Definition: International Classification of Diseases, 10th Revision (ICD 10) multiple cause code T40.1. Rates are age adjusted to the 2000 US population (not including Age Group rates). CI = Confidence Interval. *Too few cases to meet precision standard (relative standard error <30%); interpret with caution. Too few cases to protect confiden ality and/or report reliable rates.