EXPANDED MAINE DRUG DEATH REPORT FOR 2018 Marcella H. Sorg, PhD Margaret Chase Smith Policy Center University of Maine This report, funded by the Maine Office of Attorney General, provides a summary of statistics regarding drug fatalities in Maine during 2018. Data for the report were collected at the Office of Chief Medical Examiner. A drug death is identified when one or more drugs are mentioned on the death certificate as a cause or significant contributing factor for the death. Executive Summary There has been a reduction in 2018 drug deaths compared to 2017, 15% fewer drug deaths overall, with a reduction in both non-pharmaceutical and pharmaceutical opioid deaths. There were 354 total drug deaths statewide, down from 417 in 2017, and similar to 2016 levels. Of these 354 deaths, 80% were caused by opioids, frequently in combination with other drugs or alcohol. Maine is not the only state seeing a reduction in overdoses. The across-the-board reduction in both pharmaceutical and non-pharmaceutical drug deaths suggests broad influences are impacting overdose rates, for example, economic changes, the composition and combination of drugs being trafficked, and regional law enforcement efforts, as well as specific policy changes around opioids. Figure 1 shows the changes in major categories over time. Non-pharmaceutical opioid deaths, including fentanyl, fentanyl analogs, and heroin, have declined by 18%. Pharmaceutical opioid deaths, predominantly oxycodone, hydrocodone and methadone, declined by 37%. It is important to point out that the reduction in deaths may represent a decline in the lethality of specific drugs and how they are being used. It does not necessarily indicate a reduction in the numbers of individuals with opioid use disorder. Patterns of use may be changing. For example, Maine has seen an increase in the number of deaths involving cocaine over the past several years, and a small, but dramatic increase in 2018 in the number of deaths caused by methamphetamine. Heroin deaths have decreased, but the statistics on arrests by the Maine Drug Enforcement Agency suggest that heroin availability has not decreased. This year we are presenting data for all counties, regardless of the number of their total drug deaths. These totals are much smaller than the statewide total and because of those small numbers, we can expect to see changes up and down from year to year that reflect random fluctuations. 1 Number of Deaths due to Pharmaceutical vs Nonpharmaceutical Opioids Non-Pharm Opioids 300 250 200 150 Pharm Opioids 100 Non-Opioids 50 0 Pharm + Non-Pharm Opioids 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Non-Opioid 49 40 40 42 36 43 34 61 65 71 Pharm. Opioid 120 123 108 103 107 111 112 123 124 78 Pharm + Non-Pharm Opioid 2 4 0 10 7 24 31 51 53 26 Non-Pharm. Opioid 12 8 7 28 40 78 157 243 281 231 Figure 1. Overall trends in Maine drug death categories 2 Overview • Total: In 2018 there were 354 drug-induced deaths statewide, which is 42 (15%) fewer than in 2017. Of the 354 total, 283 (80%) deaths were caused by opioids alone or in combination with other drugs and/or alcohol. • Manners of death: Of the 354 drug deaths, 313 (89%) were accidental1 overdoses, 30 (8%) were suicides, and 10 (3%) were certified as undetermined manner of death. • Overall patterns of note in 2018: o Most (80%) drug deaths were caused by two or more drugs. The average cause of death involved, 3 drugs. This is about the same proportion as in 2017. o Deaths due to opioids totaled 283, a 20% reduction in number compared to 2017. o Deaths due to non-pharmaceutical opioids such as fentanyl and heroin totaled 231, (82% of opioid deaths), an 18% reduction in number compared to 2017. o Deaths due to pharmaceutical opioids totaled 78 (28% of opioid deaths), a 37% reduction in number compared to 2017. o Fentanyl and its analogs caused 217 deaths (77% of opioid deaths), a 12% reduction in number compared to 2017. o Heroin caused 74 deaths (26% of opioid deaths), a 16% reduction in number compared to 2017. o Cocaine-involved deaths totaled 90 (25% of drug deaths), a 1% reduction in number compared to 2017. Cocaine is a co-intoxicant in 32% of fentanyl deaths and 32% of heroin deaths. o Deaths due to methamphetamine totaled 26, a 62% increase from 16 in 2017. • Demographic patterns: Table 1. Demographic patterns by manner of death, 2018 All drug deaths Accidents Suicides Total 354 314 30 Average Age 42 41 50 Age Range 0-90 0-73 18-90 Percent Male 253 (71%) 230 (73%) 17 (57%) 1 Provisional accidental manner of death designations were assigned to two cases still awaiting further testing and final completion. 3 • Involvement of specific drug categories: Table 2. Frequency of specific drug categories, 2018 Specific drug or drug category causing the death (alone or in combination with other drugs and/or alcohol) Number of deaths caused by more than one drug Any pharmaceutical drug Any opioid (pharmaceutical or non-pharmaceutical) Naloxone present in the toxicology report* Any illicitly manufactured drug (includes heroin/morphine, nonpharmaceutical fentanyl, fentanyl analogs, other illicitly-manufactured opioids, cocaine, methamphetamine, and MDMA) Any non-pharmaceutical opioid drugs (heroin/morphine, fentanyl, fentanyl analogs, U-47700, mitragynine). Heroin/morphine and/or fentanyl or fentanyl analogs Fentanyl and/or fentanyl analogs (known pharmaceutical fentanyl removed) Heroin/morphine (known pharmaceutical morphine removed) Any pharmaceutical opioid (most were not prescribed to the decedent) Any benzodiazepine Cocaine Methamphetamine *Excludes cases with buprenorphine in toxicology. Number 284 198 283 97 Percent of 354 drug deaths 80% 56% 80% 27% 257 73% 231 230 217 74 78 78 90 26 65% 65% 61% 21% 22% 22% 25% 7% 4 • County/City frequencies: The following table provides totals for the counties and the six cities that had 10 or more drug deaths in 2018. Table 3. Frequency of drug deaths by county and major city TOTAL NUMBER (PERCENT) OF OVERDOSE DEATHS 2018 N=354 TOTAL NUMBER (PERCENT) OF OPIOID DEATHS 2018 N=283 PERCENT OF MAINE CENSUS POPULATION 2017 (1,335,907) Androscoggin 33 (9%) 26 (9%) 8% Lewiston 16 (5%) 13 (5%) 3% 8 (2%( 4 (1%) 5% 88 (25%) 70 (25%) 22% 44 (12%) 34 (12%) 5% Franklin 5 (1%) 5 (2%) 2% Hancock 10 (3%) 9 (3%) 4% Kennebec 43 (12%) 38 (13%) 9% 15 (4%) 14 (5%) 1% Knox 6 (2%) 3 (1%) 3% Lincoln 6 (2% 4 (1%) 3% Oxford 13 (4%) 9 (3%) 4% Penobscot 53 (15%) 39 (14%) 11% 24 (7%) 18 (6%) 2% Piscataquis 5 (1%) 5 (2%) 1% Sagadahoc 2 (1%) 0 (0%) 3% Somerset 10 (3%) 9 (3%) 4% Waldo 9 (3%) 6 (2%) 3% Washington 9 (3%) 8 (3%) 2% 54 (15%) 48 (17%) 15% 10 (3%) 9 (3%) 2% COUNTY CITY Aroostook Cumberland Portland Augusta Bangor York Sanford 5 Heroin/Morphine Deaths • Heroin/morphine deaths include any death in which the cause of death identifies “heroin” or “morphine.” We have removed all cases involving known pharmaceutical morphine, so the heroin/morphine deaths are all suspected heroin overdoses. In 2018 there were 74 deaths due to (non-pharmaceutical) heroin/morphine alone or in combination with other drugs. This is an 16% decrease from the 88 heroin/morphine deaths identified in 2017. o 57 (77%) are male and 17 (23%) are female. o Average age of heroin/morphine deaths is 38 (age range 1-69). • Involvement of co-intoxicant drugs in heroin/morphine deaths: Table 4. Frequency of co-intoxicant drugs involved in heroin/morphine deaths, 2018 Specific co-intoxicants in addition to heroin/morphine identified on the death certificate as a cause of death One or more drugs (or alcohol) in addition to heroin/morphine At least one pharmaceutical opioid in addition to heroin/morphine Non-pharmaceutical fentanyl and/or at least one fentanyl analog in addition to heroin/morphine Alcohol in addition to heroin/morphine At least one benzodiazepine in addition to heroin/morphine Cocaine was mentioned in addition to heroin/morphine Number Percent of Heroin/Morphine Deaths N=74 74 100% 13 18% 61 21 14 24 82% 28% 19% 32% 6 Non-Pharmaceutical (“Illicit”) Fentanyl and/or Fentanyl Analog Deaths • This category includes deaths caused by non-pharmaceutical (illicitly manufactured) fentanyl or fentanyl analogs. We removed all cases that involved known pharmaceutical fentanyl from these totals. There were 217 overdoses due to non-pharmaceutical fentanyl and/or fentanyl analogs in 2018. This is an 12% decrease from 247 deaths in 2017. o 169 (78%) are male and 48 (14%) are female. o The average age in illicit fentanyl/fentanyl analog deaths is 38 (age range 1-69). • Involvement of co-intoxicant drugs in non-pharmaceutical fentanyl deaths: Table 5. Frequency of co-intoxicant drugs involved in fentanyl deaths, 2018 Specific co-intoxicants in addition to fentanyl and/or fentanyl analogs identified as a cause of death FENTANYL and FENTANYL ANALOG COMBINATIONS • Fentanyl (with or without fentanyl analogs) • Fentanyl analogs (with or without fentanyl) • Both non-pharmaceutical fentanyl and at least one fentanyl analog CO-INTOXICANTS IDENTIFIED IN FENTANYL and/or FENTANYL ANALOG DEATHS • One or more drugs (or alcohol) in addition to fentanyl and/or fentanyl analogs • One or more pharmaceutical opioids in addition to fentanyl and/or fentanyl analogs • Heroin/morphine in addition to fentanyl and/or fentanyl analogs • Alcohol in addition to fentanyl and/or fentanyl analogs • One or more benzodiazepines in addition to fentanyl and/or fentanyl analogs • Cocaine in addition to fentanyl and/or fentanyl analogs • Number Percent of Fentanyl/Fentanyl Analog Deaths N=217 207 65 95% 30% 55 25% 169 78% 21 10% 61 59 28% 27% 35 69 16% 32% Fentanyl analogs identified: Table 6. Frequency of fentanyl analogs identified as a cause of death in 2018 Fentanyl Analog Identified (Some cases had more than one analog.) Acetyl Fentanyl Carfentanil Cyclopropyl Fentanyl Furanyl Fentanyl Methoxyacetyl Fentanyl Parafluorobutyryl Fentanyl Parafluoroisobutyryl Fentanyl Total Number of Cases* 48 1 2 2 4 3 10 Percent of Fentanyl AnalogInvolved Deaths N=65 74% 2% 3% 3% 6% 5% 15% 7 418 376 354 305 272 208 179 176 173 183 167 166 165 164 163 167 163 162 160 155 154 155 149 153 147 142 140 141 139 134 136 129 259 254 257 231 198 176 34 30 8 54 47 18 66 60 13 60 51 15 91 90 74 31 35 47 50 61 59 49 30 40 22 19 46 19 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Total Pharmaceutical Illicit Figure 2. Number of drug-induced deaths in Maine, with subtotals for deaths caused by any pharmaceutical drugs and for deaths caused by any illicit (non-pharmaceutical) drugs. Most deaths are caused by more than one drug. Pharmaceutical and illicit drugs may be combined to cause death. 8 Total Deaths due to Pharmaceutical Opioids Compared to Non-Pharmaceutical (Illicit) Opioids, Alone or in Combination 450 400 350 300 250 200 150 100 50 0 2010 2011 2012 2013 2014 2015 2016 2017 2018 Total 167 155 163 176 208 272 376 418 354 Pharm Opioid 123 108 103 107 111 112 123 124 78 8 7 28 40 78 157 243 281 231 Non-Pharm Opioid Figure 3. Comparison of the number deaths due to pharmaceutical versus non-pharmaceutical opioids, alone or in combination with other drugs and/or alcohol. Deaths due to Heroin/Morphine and Non-Pharmaceutical Fentanyl and/or its Analogs 450 400 350 300 250 200 150 100 50 0 Total Heroin/Morphine Non-Pharmaceutical Fentanyl 2010 167 8 0 2011 155 7 0 2012 163 28 0 2013 176 40 1 2014 208 57 32 2015 272 107 87 2016 376 120 194 2017 418 88 247 2018 354 74 217 Figure 4. Total drug deaths with subtotals for the number of deaths due to heroin/morphine and nonpharmaceutical fentanyl and/or its analogs. Although separate totals are provided for heroin/morphine and fentanyl/fentanyl analog fatalities, many deaths include both drug categories. 9 Deaths Due to Heroin/Morphine (HM) and NonPharmaceutical Fentanyl and/or its Analogs, Alone or in Combination with Each Other 300 250 200 150 100 50 0 Non-pharm Fent, without Heroin HM, without Non-pharm Fent HM and Non-pharm Fent 2010 0 8 0 2011 0 7 0 2012 0 28 0 2013 0 39 1 2014 21 46 11 2015 50 70 37 2016 119 45 75 2017 193 34 54 2018 156 13 61 Figure 5. Total deaths due to heroin/morphine (“HM”) with non-pharmaceutical fentanyl (Non-pharm Fent”) and/or its analogs, alone or in combination with each other. 10 Deaths due to Key Pharmaceutical Opioids, Alone or in Combination 60 50 40 30 20 10 0 Oxycodone Methadone Buprenorphine Hydrocodone (Pharm.) Fentanyl (Pharm.) Morphine 2010 47 51 5 17 10 17 2011 35 43 3 17 16 13 2012 45 32 5 10 10 8 2013 34 38 7 10 9 10 2014 42 30 7 18 10 7 2015 37 38 9 17 6 4 2016 46 41 12 18 3 7 2017 53 31 22 9 3 3 2018 29 19 14 12 2 2 Figure 6. Number of deaths caused by key pharmaceutical opioids, alone or in combination with other drugs. Note that these fentanyl cases are pharmaceutical fentanyl. 11 Cocaine Deaths 100 90 80 70 60 50 40 30 20 10 0 Cocaine 2010 11 2011 14 2012 13 2013 10 2014 24 2015 35 2016 60 2017 91 2018 90 Figure 7. Number of deaths caused by cocaine, alone or in combination with other drugs 12