Indicator Dashboards
Opioid Dashboard

Analysis

In 2016, opioid involved deaths continued to increase for Minnesotans. There was a 18% increase in opioid involved deaths from 2015 to 2016. The greatest number of opioid involved deaths continues to be due to commonly prescribed opioids; there were 194 prescription opioid overdose deaths in 2016. The number of drug overdose deaths that involved other opioids and methadone (i.e. typically prescribed opioids, such as codeine, oxycodone, or hydrocodone) has remained stable over the past three years. Since 2010, heroin deaths have increased rapidly; there were 150 heroin involved deaths in 2016 or a 32% increase in heroin-involved overdose deaths from 2015. Other synthetic opioids (e.g. fentanyl, fentanyl analogs, tramadol) have increased nearly 83% since 2015; there were 99 synthetic opioid involved deaths in 2016. Of the 99 synthetic opioid involved deaths, 87 had fentanyl listed on the death certificate as a cause of death.

In 2016, there were 395 opioid-involved deaths (including prescriptions, heroin, fentanyl, and fentanyl analogs), 140 psychostimulants/methamphetamine-involved deaths, 103 benzodiazepine (e.g. Valium), and 44 cocaine-involved deaths in Minnesota.

Unfortunately, due to limitations of death certificates, it is not possible to determine where the opioids involved in the drug overdose death originated from (e.g. licit or illicit source), apart from heroin. Furthermore, counterfeit pills are being produced with increased precision and, without lab testing, can be difficult to discern from licitly produced opioids. Therefore, there is potential for significant overlap between these drug categories and a need for proper toxicology testing for each drug overdose death.

In the seven county metro area, all drug categories of overdose deaths increased, some dramatically, from 2015 to 2016. In the metro area, opioid deaths increased significantly, driven by a sharp increase in heroin and other synthetic opioid involved deaths. Other opioids and methadone increased 22%; heroin-involved deaths increased 47%; benzodiazepine and psychostimulant-involved deaths increased 57%; and other synthetic opioid-involved deaths increased 146%.

In greater Minnesota, different patterns emerge when examining drug overdose deaths. Other opioid and methadone-involved deaths decreased 12% from 2015, while heroin, synthetic opioid, and benzodiazepine-involved deaths all remained relatively stable from 2015. However, psychostimulant-involved (e.g. methamphetamine) deaths increased over 80% from 2015 to 2016 in greater Minnesota. There were 71 methamphetamine involved deaths in 2016 in greater Minnesota.

These are two very different phenomena in 2016 that highlight urban and rural differences.

*Note: Above graph is for all drug overdoses, including opioids, methadone, heroin, synthetic opioids, cocaine, psychostimulants, and benzodiazepines

Minnesota ranked sixth lowest among all states in overall drug overdose mortality rate in 2015 (10.6 per 100,000 residents). In 2015, Minnesota ranked first amongst all states when measuring the disparity-rate ratio of deaths due to drug overdose among American Indians relative to whites. Native American Minnesotans are five times more likely to die from a drug overdose than white Minnesotans. In 2015, Minnesota ranked first amongst all states when measuring the disparity-rate ratio of deaths due to drug overdose among African Americans relative to whites. African American Minnesotans are twice as likely to die from a drug overdose than white Minnesotans. Both of these rate disparities—between Native Americans/whites and African Americans/whites—are the greatest rate disparity based on race in the United States.

For comparison, the American Indian population represents 1.5% of the total population of Minnesota; the American Indian population represents 6% of all drug overdose deaths to Minnesota residents. The African American population represents 7% of the total population of Minnesota; the African American population represents 10% of all drug overdose deaths to Minnesota residents.

Final 2016 data show the disparity has continued and worsened. While the white drug overdose mortality rate increased from 10.1 to 11.7 per 100,000 white residents, the American Indian mortality rate increased from 47.3 per 100,000 residents to 64.6 per 100,000 residents, and the African American rate increased from 20.8 per 100,000 residents to 24.0 per 100,000 residents. Although national 2016 mortality data are not yet available, the disparity rate ratio is likely to remain among the highest in the United States.

Source

Minnesota Death Certificates

Description: Drug overdose death data come from Minnesota death certificates. After a death occurs, a death investigation is completed, along with an autopsy (94% of drug overdose deaths had an autopsy completed in 2016), and a medical examiner or coroner makes a determination of the cause and manner of death. The cause of death information is then typed into the corresponding sections of the death certificate. Once the medical examiner certifies and completes a death certificate, the information is then sent to the Office of Vital Records (OVR) at the Minnesota Department of Health (MDH). Data quality checks are completed to ensure the death certificate was completed properly and accurately. It is then sent to the National Center for Health Statistics (NCHS) where the literal text on the death certificate in the cause of death fields is converted from text to the International Classification of Diseases and Related Health Problems, 10th revision (ICD-10) codes. The NCHS uses a specially made computer program to code the literal text on the death certificate into ICD-10 codes according to the information listed on the death certificate. This program allows for one underlying cause of death and up to 20 contributing causes of death. Once this program is run and the data are assigned ICD-10 codes, the data are returned to the OVR in the MDH and made available for analysis.

To identify drug overdose deaths and the specific drugs involved from the entire death certificate file, a two-step analysis is completed. First, only death certificates with an underlying cause of death in the ranges of X40-X44, X60-X64, X85, or Y10-Y14 are selected. From there specific ICD-10 drug codes in the contributing cause of death fields are searched to identify all drug overdose deaths that involved each drug category of interest (T36-T50). The drug categories are not mutually exclusive, meaning a death with heroin (T40.1) and cocaine (T40.5) will be counted in both drug categories. Data are then summarized by demographic and geographic variables of interest.

Geographic level data are available: State, trauma regions, EMS regions, county, ZIP code for decedent residence, death location, or injury location

Strengths: The strengths of death certificate data include the completeness of reporting from across the state, as well as from other states when Minnesota residents die in another state. There is also consistency of reporting across and between states ensuring the data can be easily analyzed. Additionally, data can be easily grouped by the larger drug categories to allow for examination of trends in specific drug categories.

Limitations: The limitations of the death certificate data include timeliness in completing the death certificates. The death investigation and autopsy process takes considerable time and toxicology testing may take further time to properly identify the drugs involved in the death. Due to Minnesota’s current medical examiner and coroner system, there is also variability in how drug overdose deaths are reported. This includes variation in the details and specificity listed on a death certificate in terms of the specific drugs involved in a death. For example, death certificates that only list mixed drug toxicity as a cause of death do not provide the level of detailed information required to properly code the death with ICD-10. Without the correct ICD-10 code the drug overdose death will likely be grouped with “other drugs” (13.8% of drug overdose deaths with T50.9, other and unspecified drugs, as only T-code listed on death certificate). This lack of specificity does not allow for a proper examination of deaths. Finally, death certificates cannot be used to quickly identify new drug trends because of the time it takes to complete toxicology and for death certificates to be finalized and made available for analysis.

Perform your own analysis:

• CDC WONDER The CDC WONDER online mortality databases utilize a rich online query system for the analysis of public health data. Analyses of death certificates can be conducted for the U.S., as well as for any state, including Minnesota.
• CDC WISQARS CDC’s WISQARS (Web-based Injury Statistics Query and Reporting System) is an interactive, online database that provides fatal and nonfatal injury, violent death, and cost of injury data from a variety of trusted sources. Researchers, the media, public health professionals, and the public can use WISQARS data to learn more about the public health and economic burden associated with unintentional and violence-related injury in the United States.
• Minnesota Vital Statistics Interactive Queries These data are population based and include all deaths occurring to Minnesota residents regardless of where the event occurred. Grouping variables include cause of death, age, gender and race.
  

Resources

All Opioid Overdose Deaths

Drug Overdose by Race

Preliminary 2017 Drug Overdose Deaths in Minnesota
Preliminary report on drug overdose death trends in Minnesota.

MDH Drug Overdose Death among Minnesota Residents 2000-2016
MDH report and analysis of data regarding drug overdose deaths over 16 years.

Judy's Rx Awareness Story

Fentanyl Safety Recommendations for First Responders The White House National Security Council put together a federal interagency working group made up of medical, public health, law enforcement, fire/EMS, and occupational safety and health disciplines to create a one-page, user friendly resource that is tailored to first responders.

Minnesota Coroners’ & Medical Examiners’ Association
Information about the MN Coroner’ and Medical Examiners’ Association, including forensic groups and programs, and links to MN Statutes Chapter 390—Coroner, Medical Examiner and Chapter 13.83—Medical Examiner Data

Controlled Substances
Drug Enforcement Administration (DEA) definition of controlled substances

Warning: This Drug May Kill You
HBO Documentary released in 2017 sharing the stories of four families devastated by opioid addiction

Prevention

When it comes to opioid overdose death, some of the upstream actions or promising practices include:

• The creation of real-time alerts for fentanyl-laced products. Some ideas have included an amber-alert type of mechanism to let people know when and where a fentanyl-laced product was found.
• A balanced approach to addressing the opioid epidemic. Prescription opioids still account for the greatest number of deaths in Minnesota, and heroin deaths are on the rise, and fentanyl and fentanyl analogs are a real and emerging concern in Minnesota. Our efforts must address prescription opioids, heroin, and fentanyl and fentanyl analogs.
• More timely, accurate, and consistent reporting of cause of death (e.g. less variability between medical examiners and coroners across the nation to enable more accurate comparisons and trends nation-wide).
• Additional toxicology reports to ensure that the type of drug(s) involved in the death are accurately captured (e.g. standard toxicology reports show if opioids, including fentanyl are present, but further testing is needed to test for the presence of fentanyl analogs).
• More inquiry into deaths categorized as natural when only prescription pain pills are present at the scene or on the prescription history as they may be intentional/suicide or unintentional/accidental.

Please visit the Prevention tab under each indicator for additional upstream actions or promising practices.

Analysis

In 2017, nonfatal emergency room (ER) visits for all-opioid involved, opioid (excluding heroin), and heroin overdoses increased, continuing the steady rise in ER visits over the past ten years. The gray area on the graph denotes the transition from ICD-9-CM to ICD-10-CM, effective October 2015. Recent data should not be compared to data from before the change. This is the reason why the two dots over this transition period are not connected.

From 2010 to 2017, males had a greater number of ER visits for heroin overdoses than females. The number of ER visits for heroin overdoses increased for both men and women from year to year.

From 2010 to 2017, males also had a greater number of ER visits for all-opioid involved overdoses than females. The number of ER visits for all-opioid involved overdoses increased for both men and women from year to year.

Over the past ten years, nonfatal ER visits for all-opioid involved overdoses in all age categories have increased. Individuals 15-34 years of age accounted for the most ER visits for all-opioid involved overdoses in 2016 and 2017.

2017 County-Level Nonfatal, Opioid-Involved Overdoses
Tables with Minnesota county-level data on nonfatal emergency department (ED) visits for all-opioid, opioid (excluding heroin) and heroin overdoses.

Source

Minnesota Hospital Discharge Database

Description: Data for nonfatal hospital-treated overdose come from the Minnesota Hospital Discharge Database provided by the Minnesota Hospital Association. Data are provided quarterly to the Minnesota Department of Health. These data include all inpatient and emergency department hospital treatments at acute care, non-federal in-state hospitals and some border hospitals. Stand-alone psychiatric facilities are not included; however, psychiatric admissions within a hospital are included. There are 147 hospitals in Minnesota, including non-acute care facilities; 137 are members of the Minnesota Hospital Association; 135 are included in the all-age injury hospital discharge database at the Minnesota Department of Health. There are a small number of hospitals who are not members of the Minnesota Hospital Association that will not be in the data.

Geographic level data are available: State, trauma regions, EMS regions, county of residence, ZIP Code of residence

Strengths: The data represent a majority of hospitalizations for drug overdose in Minnesota, regardless of the insurance carrier or payer. The data are also de-duplicated prior to analysis, which results in the removal of counting an individual hospitalization more than once.

Limitations: Hospital discharge data are primarily intended for billing purposes, not public health surveillance. The data also do not currently contain race or ethnicity. The transition to ICD-10-CM in the final quarter of 2015 (October – December 2015) makes comparisons inaccurate, if not impossible, to previous years. Trend data is available from 2000 to 2014, and estimates for 2015 are included in the charts. Data for 2015 should be interpreted cautiously and trends should not include 2015 data because of the transition to ICD-10-CM. Trend data will start over from 2016 onward.

Perform your own analysis:

• Minnesota Injury Data Access System To support its mission of preventing injuries in Minnesota, the Minnesota Department of Health has developed MIDAS, the Minnesota Injury Data Access System. It will enable you to more easily learn about the injury and violence data for Minnesotans, whether for a specific county, for a type of injury, or by gender, time frame, or other factor.

Resources

Emergency room visits for all opioid involved overdoses

Opioid overdose deaths are the most visible outcome from the opioid epidemic. However, death is only one part of the picture of opioid overdoses. For every one death, there are two hospitalizations, four emergency department visits, and seven emergency medical service responses for opioid overdoses. There is overlap between the groups (i.e. an individual may be treated in the emergency department and then die), as well as opioid overdoses that are not captured within this pyramid (e.g., naloxone administered by a family member). The pyramid aims to demonstrate the larger impact of opioid overdoses and who should be involved in the response.

MDH Naloxone Protocol
Information about the Naloxone Protocol that pharmacies can adopt in order to dispense naloxone to anyone who is at risk for, or knows someone who is at risk for, an opioid overdose

MDH Opioid Overdose
Information about the signs and symptoms of an opioid overdose and information about naloxone (who should get it, why to get it, where to get it, how to administer it, and what to expect during withdrawal)

MDH Naloxone Videos

• What is naloxone and why is it important?
• Who needs naloxone?
• Where do I get naloxone?
• How should I store naloxone?
• What is the shelf life of naloxone?
• What are the signs and symptoms of an opioid overdose?
• What do I do when someone overdoses on opioids?

Veterans Administration Opioid Education & Naloxone Distribution (OEND)
This video shows a medical provider discussing the risk of an opioid overdose and offering naloxone to a patient who is taking prescription opioids. While it is no longer recommended to start anyone on opioids for chronic pain, there are patients who are already taking opioids for medical reasons or are actively using prescription and/or illicit opioids. In these cases, it is recommended to co-prescribe naloxone to be prepared in the event of an opioid overdose emergency.

University of Minnesota Naloxone Resource Site
CME/CPE presentation on identifying risks, signs and symptoms of opioid overdoses and understanding the various naloxone formulations. Healthcare providers who watch the video are able to earn CME/CPE credit at no cost.

Nonfatal, Unintentional Poisonings in Minnesota from 2012-2017 (PDF)
Data brief on nonfatal, unintentional poisonings among Minnesotans from 2012-2017 using Minnesota Hospital Discharge Data. Key findings include:

• Nonfatal, unintentional poisonings decreased slightly from 2016 to 2017 for the first time
  in many years.
• Males continue to experience more overdoses than females.
• Nonfatal, unintentional poisonings are highest for 1-4, 25-29, and 50-59 year olds, but are
  the result of different types of poisonings.
• The Seven-County Metro and Greater Minnesota differ in nonfatal, unintentional poisoning
  trends across age groups.

Minnesota Poison Control
Established under MN State Statute 145.93, the Minnesota Poison Control System is responsible for providing immediate medical treatment recommendations for poisonings and overdoses to the general public and health care professionals. This service is provided statewide by calling 1-800-222-1222 and is available 24/7 with no direct cost to the user. Opioid overdoses fall within this responsibility. MN Poison Control encourages all Minnesotans (public, law enforcement, EMS, health care professionals) to utilize the MN Poison Control for all overdoses, especially opioid overdoses that required naloxone administration. The MN Poison Control can assist with safe medical management and collection of public health data that will aid efforts to combat the opioid epidemic.

Statewide Community-based Organizations
As a part of the State Targeted Response (STR) Grants through Department of Human Services (DHS), organizations were awarded funds to provide Naloxone overdose training and kits free of charge. The following community-based organizations provide Naloxone overdose training and kits free of charge:

• Steve Rummler HOPE Network—Call 952-493-3937 or sign up for training from the Steve Rummler HOPE Network.
• Rural AIDS Action Network (RAAN)—Call 320-257-3036.
• Meridian/Valhalla—Call 651-925-8200.

Prevention

When it comes to nonfatal overdose, some upstream actions and promising practices include:

• Standardizing notification from the hospital to the primary clinic, and additional discharge planning procedures following a nonfatal overdose
• Creating a health information exchange (HIE) in Minnesota to connect hospital, clinic, treatment, claims and other social services data
• Notifying prescribers when a prescription they wrote was involved in a law enforcement encounter via the Prescription Monitoring Program (PMP) from the Board of Pharmacy (BoP) or the Drug Monitoring Initiative (DMI) from the Department of Public Safety (DPS)
• Creating one state-wide strategy for collection of naloxone administration data
• Increasing skills and knowledge about naloxone administration by health care professionals, EMS, law enforcement, and lay people
• Increasing participation in the Naloxone Protocol so pharmacies can dispense naloxone to anyone who is at risk for, or knows someone who is at risk for, an opioid overdose
• Expanding co-prescribing of opioids and naloxone
• Expanding Screening, Brief Intervention, and Referral to Treatment (SBIRT) services in primary care
• Deploying care coordinators, peer support specialists, or other wrap-around services during a nonfatal overdose to coordinate the transition of care out of the hospital, treatment, incarceration, or detox and into follow-up care

Please visit the Prevention tab under each indicator for additional upstream actions and promising practices.

Analysis

Alcohol remains the primary substance at admission to substance use disorder treatment services for adults in Minnesota. The number of admissions for alcohol has been decreasing since 2009. In 2016, methamphetamine was the second leading primary substance at time of admission to treatment, and has increased rapidly since 2010. Treatment admissions for heroin have also seen a steady increase since 2010, while treatment for other opiates have declined since 2010. The green dashed line on the graph signifies injection drug route as the primary route of administration for individuals at admission to treatment services. There has been a steady increase in injection drug use as the primary route of admission since 2010.

Prevalence of past year non-medical pain reliever use among individuals 12 years or older is 3.56%. Past year non-medical pain reliever use increases from those 12-17 years of age (3.96%) to 18-25 years of age (8.38%). Individuals 26 years of age and older have the lowest prevalence of past year non-medical pain reliever use (2.73%).

In the 2013 Minnesota Student Survey, data was not collected on any use of prescription pain relievers not prescribed for them by their doctor. In 2016, 3.20% of students reported any use of prescription pain relievers not prescribed to them within the past 12 months. The percentage of students reporting used increased with grade, from 2.30% among 8th graders, to 2.80% among 9th graders, and 4.90% among 11th graders. Among all grades, use was similar between males and females.

There were no differences in the percent of adults reporting any use of prescription pain relievers not prescribed for them by their doctor within the past 12 months in 2004/2005 compared with 2010. Any prescription pain reliever use not prescribed to them was also similar between males and females.

Percent of students reporting any past 30 day use of prescription drugs not prescribed for them was 5.30% in 2013 and 4.70% in 2016. Use of prescription drugs increased from 8th to 11th grades in 2013 and 2016. The percent of students reporting any past 30 day use is similar for females and males.

In 2015, the percent of adults reporting any use of prescription drugs not prescribed for them by their doctor was 2.70%. Respondents 25-44 year of age had the greatest percentage of prescription drug use not prescribed to them, while the least percentage was among respondents 18-24 years and 65 years of age and older.

Prevalence of past year heroin use among NSDUH respondents 12 years of age and older was 0.35%. Past year heroin use increased from respondents 12-17 years of age (0.11%) to 18-25 years of age (0.85%), and was lower among respondents 26 years of age and older (0.30%).

In 2015, there was a total of 10,332 admissions to Minnesota treatment facilities for opioid use. The number of admissions was highest among those 25-44 years of age. Among individuals 18 years of age and older, males had a greater number of admissions.

This table provides the enrollment count, treatment capacity, and percentage of capacity for all opioid treatment programs in Minnesota. Two of the treatment centers are above capacity (greater than 100%).

Source

National Survey on Drug Use and Health (NSDUH)

Description: The National Survey on Drug Use and Health (NSDUH) is the primary source of information on the prevalence, patterns, and consequences of alcohol, tobacco, and illegal drug use and abuse and mental disorders in the U.S. civilian, non-institutionalized population, age 12 and older. The survey generates estimates at the National, state, and substate levels.

Geographic level data are available: National, state, substate/metro areas

Strengths: The NSDUH obtains a representative sample of respondents to allow for prevalence estimates of mental illness and substance use disorder from survey responses. The data can also be used to provide prevalence estimates in demographic or geographic subgroups and determine the need for substance use or mental health treatment services. It also allows for the analysis of trends over time from common questions that have remained in the survey.

Limitations: Due to the sensitive nature of some of the questions asked from the survey, respondents may under report or fail to report certain behaviors, such as illegal drug use. The survey excludes homeless persons who do not use shelters, military personnel on active duty, and residents of institutional group quarters, such as jails or hospitals. Revisions of the survey that add or delete questions also impede the ability to measure trends over time. Small sample sizes also limit the ability to analyze certain geographic or demographic subgroups.

Perform your own analysis:

• Substance Abuse & Mental Health Data Archive (SAMHDA) Browse and download data, or analyze data online with the public use data analysis system. Analyze data from the National Survey on Drug Use and Health from 2002 to 2015 in order to better understand substance use and mental health data for the U.S.

Minnesota Student Survey (MSS)

Description: The Minnesota Student Survey (MSS) is conducted every three years among three populations of students in Minnesota public schools:

• students in regular public schools, including charter schools and tribal schools 
• students in alternative schools and Area Learning Centers
• students in juvenile correctional facilities

The survey asks questions about activities, experiences and behaviors. Topics covered include tobacco, alcohol and drug use, school climate, physical activity, violence and safety, connections with school and family, health and other topics. Questions about sexual activity are asked only of high school students. The survey is administered jointly by the Minnesota Departments of Education, Health, Human Services and Public Safety.

Geographic level data are available: state, region, county

Strengths: The MSS is a major source of information about the thoughts and experiences of Minnesota’s young people. Eighty-five percent (85%) of Minnesota school districts participated in the 2016 survey, and nearly 169,000 students in regular public schools took the survey. The MSS allows for sub-state analysis and the ability to track behaviors over time.

Limitations: The survey asks questions about behaviors or beliefs that are sensitive in nature, which may result in the underreporting of these behaviors or beliefs. Analyses are also limited by small sample sizes in certain geographic or demographic subgroups. Since the survey is administered in school, students not in or absent from school do not have the opportunity to participate in the MSS. Trend analyses can also be limited as the survey is updated and questions are added or removed.

Perform your own analysis:

• Substance Use in Minnesota (SUMN) provides data on over 100 indicators of alcohol, tobacco, and other drug consumption patterns, consequences, and contributing factors in Minnesota. Data are provided at the county level, regional, and state level, and by demographic group when possible.

Minnesota Survey of Adults Substance Use (MNSASU)

Description: The Minnesota Survey on Adult Substance Use (MNSASU) is a statewide survey conducted periodically by the Minnesota Department of Human Services to gather information about substance use and treatment need for substance use disorders among adults in Minnesota. The survey also provides some information on mental health and overweight/obesity rates among the adult population.

Geographic level data are available: state, region

Strengths: A stratified random sample design was used to provide more accurate measurements for minority population, as well as the seven prevention planning regions. The survey also used standardized questions to assess mental health and substance use from respondents.

Limitations: The survey is completed through a telephone interview, which may lead people to answer sensitive questions differently. This may lead to underreporting of certain health behaviors or conditions. Additional subgroup analyses may also be limited because of small sample sizes.

Perform your own analysis:

• Substance Use in Minnesota (SUMN) provides data on over 100 indicators of alcohol, tobacco, and other drug consumption patterns, consequences, and contributing factors in Minnesota. Data are provided at the county level, regional, and state level, and by demographic group when possible.

Minnesota Department of Human Services: Drug and Alcohol Abuse Normative Evaluation System (DAANES)

Description: The DAANES is designed to provide policy-makers, planners, service providers and others in Minnesota with access to current information about chemical dependency treatment activities across the continuum of care. The Department of Human Services is required by statute to collect sufficient information to evaluate the efficiency and effectiveness of treatment for chemical dependency. In addition, the federal Substance Abuse and Mental Health Services Administration (SAMHSA) of the Department of Health and Human Services has mandatory reporting requirements through the National Outcomes Measurements (NOMs) monitoring system. SAMHSA requires that all treatment providers who receive any state or federal funds report on this system for all treatment admissions regardless of funding source. In Minnesota, DAANES is used to meet both state and federal reporting requirements.

Geographic level data are available: state, region, county

Strengths: The DAANES provides information on the primary substance at admission to substance use disorder treatment services for adults and adolescents. This allows for the tracking of trends in admissions for certain categories of drug, as well as primary route of administration. These data paired with complimentary data sources can provide a more comprehensive picture of substance use in Minnesota.

Limitations: Relying on the primary substance at admission to substance use disorder treatment services does not capture the complete picture of substance use, as there is often more than one drug individuals may have used. Additionally, it does not put into perspective treatment capacity and how the need is or is not being met in Minnesota. The DAANES does also not allow for quick identification of emerging drug trends.

Perform you own analysis:

• Substance Use in Minnesota (SUMN) provides data on over 100 indicators of alcohol, tobacco, and other drug consumption patterns, consequences, and contributing factors in Minnesota. Data are provided at the county level, regional, and state level, and by demographic group when possible.

Resources

Primary substance at admission to SUD treatment services for adults

Center for the Application of Prevention Technologies (CAPT) Grantee Stories, Tools and Resources
SAMHSA shares webinars, publications, and toolkits on various opioid overdose prevention efforts including reducing demand, supply, and harm of prescription opioids.   

Change the Conversation About Opioid Use Disorders

Facing an Everyday Killer
The National Safety Council developed a short film that brings opioid users face-to-face with those who have lost a loved one.  The opioid epidemic is the worst drug crisis in US history, directly impacting one in four Americans. 

Fast Tracker for Substance Use Disorder Treatment
Searchable online tool for statewide Substance Use Disorder (SUD) services to assist individuals, family members, detox programs, assessors, care coordinators, physicians, and others to quickly access SUD service openings statewide (e.g. choose Addictions, Chemical Dependency, or Detoxification in the “Search for Clinics” section of the website). Substance Use Disorder treatment programs and detoxification programs licensed by DHS must update program openings on a daily basis.

Safe Harbor/No Wrong Door
Safe Harbor provides victim-centered, statewide response for sexually exploited youth. No Wrong Door is a comprehensive, multidisciplinary, and multi-state agency approach to ensure communities across Minnesota have the knowledge, skills and resources to effectively identify sexually exploited and at-risk youth. To learn more and access services, visit Regional Navigators, Housing, and Protocol Development and Training. If you or someone you know is being sexual exploited or trafficked, please contact your Regional Navigator or contact the Day One Hotline to learn more about services available in your community at 1-866-223-1111.

The Psychological and Physical Side Effects of Pain Medications
Dr. Donald Teater, Medical Advisor for the National Safety Council the risks of opioids including loss of family and community, lifelong disability, dependence and addiction, serious adverse events, and overdose death.

CAGE-AID
SAMHSA toolkit for the brief chemical dependency screening tool, CAGE-AID

SBIRT Services
SAMHSA explanation of screening, brief intervention, and referral to treatment (SBIRT) services

DSM 5 Criteria for Substance Use Disorder
List of the diagnostic criteria for a Substance Use Disorder

Prescription Opioids and Heroin
Explanation of the relationship between prescription opioids and heroin from the National Institute on Drug Abuse (NIH)

Minnesota Student Survey (MSS)
Information about the Minnesota Student Survey, which asks questions about activities, experience, and behaviors of 8th, 9th, and 11th graders, including alcohol and drug use

Minnesota Prevention Resource Center (MPRC)
Resource to enhance the capacity of people interesting in preventing problems resulting from alcohol, tobacco, and other drugs

Shatterproof Substance Use Cost Calculator
Tool to calculate the cost of substance use (including prescription drug misuse, alcohol misuse, opioid and heroin addiction as well as misuse of other illicit drugs and marijuana) in your profession based on size of employee base, industry, and state.

Partnership for Drug-Free Kids
National helpline for parents and caregivers who are worried about their child's substance use or substance use disorder.

Substance Use in Minnesota
Minnesota data on alcohol, drugs, risk and protective factors, and mental health by region and demographics

National Safety Council Opioid Toolkit
Interactive PDFs including facts about sharing medication, how to talk to your medical provider, safe disposal, drug safety for employers, and chronic back pain information

2014-2015 National Survey on Drug Use and Health: Model-Based Prevalence Estimates
Prevalence estimates of alcohol, tobacco, other drugs, mental health by state

Recovery Community Organizations funded by DHS to provide peer recovery support services for substance use disorder and addiction:

• Minnesota Recovery Connection
• Recovery is Happening

SAMHSA Substance Use Disorder
Facts on common substance use disorders including Opioid Use Disorder

SAMHSA Buprenorphine Treatment Physician Locater
Find physicians authorized to treat opioid dependency with buprenorphine (e.g. suboxone, subutex) by state

Licensing Look Up
Look up licensed providers who specialize in the treatment of substance use disorder that involves injection drug use

Minnesota Treatment Centers and Programs
Guide to alcohol and drug treatment centers and programs in Minnesota

Rule 25 Assessment
List of referral numbers for counties in Minnesota

AA Meeting Locater
List of AA meetings throughout Minnesota

NA Meeting Locater
A list of NA meetings throughout Minnesota

Prevention

When it comes to use, misuse, and substance use disorder, some upstream actions and promising practices include:

• Non-opioid treatments: The National Institute of Health (NIH) is researching many solutions including, but not limited to a fentanyl vaccine, non-addictive opioids, and targeting pain receptors for specific kinds of pain (e.g. low back pain that stops at the knee, low back pain that radiates to the feet).
• Integrated care: There is more and more movement to integrated care, with the increased understanding about how medical, mental, dental, chemical and sexual health are interrelated.   A clinical decision in one area or discipline is impacted by another clinical decision.   In order to achieve a comprehensive health care system, health information privacy acts and data sharing agreements need further exploration.   
• Effective treatment to prevent self-medicating: Opioids are used to alleviate suffering.  The suffering may be from physical pain, trauma, mental health, and/or chemical health. The root causes of suffering need to be addressed to prevent self-medicating with licit and illicit substances. 
• Genetic testing research: Expand the research on genetic testing to identify medications for mental and chemical health conditions that are more likely to be effective based on patient’s specific genotype. One of the root causes for prescription opioid misuse and substance use disorder is a lack of access to or efficacy of interventions. Patients are looking for effective solutions to alleviate suffering from physical pain and/or mental health conditions. Opioids are, unfortunately, very effective at numbing or escaping. Genetic testing is one tool for providers to identify effective interventions, without having to test out multiple ineffective solutions first. 
• Transition from prescription opioids to heroin: Develop deeper understanding, from a user’s perspective, of the transition from prescription opioids to heroin or other illicit substances.   Professionals within the chemical health arena, the harm reduction community, and active users have a lot of knowledge and/or lived experience with the progression of a substance use disorder; further understanding may reveal opportunities for early intervention or treatment modalities that are not currently used.
• Culturally responsive interventions: Inquire about culturally and spiritually based meaning with regard to the use of prescription and/or illicit substances. Tailor interventions towards specific cultural groups or faith-based communities. For example, in broad generalizations: Muslim patients have increased motivation for behavior change during Ramadan, Karen patients have grown up with recreational poppy use, and Peyote has been used for thousands of years for medicinal and ritualistic purposes in some Native American tribes.
• Understanding the central nervous system’s response to pain: A patient’s pain sensitivity increases with long-term opioid use; the central nervous system’s alarm system is no longer sending accurate signals. Part of recovery from long-term opioid use includes addressing the central nervous system’s response and teaching the body that life can be safe again. Health systems that are skilled in trauma-informed practices are beginning to explore holistic healing from long-term chronic pain and/or long-term opioid use.
• Integration of chemical health treatment records: In order to protect the privacy of individuals within chemical health treatment, admissions data is kept separate from other claims data. However, the lack of integration of chemical health data has also posed many challenges to coordinating care, transitions of care, and monitoring. For example, primary care clinics are often unaware of whether a patient is engaged in methadone treatment, unless the patient voluntarily discloses this information. At this time, it is still possible for a patient to be engaged in methadone treatment at more than one clinic; methadone clinic treatment is not tracked in the Prescription Monitoring Program (PMP). In addition, a patient’s involvement in a methadone clinic shapes their daily experience, such as options for employment or how far a patient can travel away from home each day. 

For additional prevention strategies and resources to address substance use and misuse, visit the Center for the Application of Prevention Technologies (CAPT).

Please visit the Prevention tab under each indicator for additional upstream actions and promising practices.

Analysis

The blue bar shows registered accounts in the database arranged by the board that licenses the individual. The green bar shows the number of individuals that are licensed by that particular board. Note: The number of prescribers includes all prescribers licensed by the various boards regardless of where they practice or if they have a DEA registration to prescribe controlled substances. There are licensees within these licensing boards that do not actively prescribe or treat patients (e.g. administrative positions, research, education, etc.). There are also individuals included in the total licensed professional column that are licensed in Minnesota but may practice in another state or hold an active license but may be retired or not practicing and would therefore not need to access the Minnesota PMP. For these reasons, it is important to remember while viewing the data that it is unlikely that 100% of prescribers and pharmacists licensed in Minnesota would obtain access to the Minnesota PMP. Licensed professionals included under Dentistry are DMD and DDS, under Pharmacy are RPh, and under Medical Practice are MD, DO, PAs and Residents. The column representing total licensed professionals by the Board of Nursing represents only APRNs who are eligible to register with the DEA to prescribe controlled substances.

From 2010 to 2017, the number of account holders that queried the PMP steadily increased from 2,087 in 2010 to 14,632 in 2017. The total number of PMP queries also increased from 79,479 in 2010 to 1,244,173 in 2017. Increases in both of these numbers is promising, and it is hoped that the trend towards more utilization of the PMP continues.

The crude rate of opioids dispensed per 1,000 residents comes from the Minnesota Prescription Monitoring Program. The overall rate of opioids dispensed to Minnesota residents in 2017 was 517.5 per 1,000 residents. Among the opioid categories, there was variation in the dispensing rate. Oxycodone (180 per 1,000 residents) and hydrocodone (155.3 per 1,000 residents) had the highest rate of dispensing. Fentanyl (11.7 per 1,000 residents) and hydromorphone (15.5 per 1,000 residents) had the lowest dispensing rate. Variation was also seen by county in the rate of opioids dispensed. The top five counties for the overall rate of opioids dispensed were Kanabec, Aitkin, Mille Lacs, Wadena, and Pine; the lowest five counties for the overall rate of opioids dispensed were Houston, Dodge, Olmsted, Nobles, and Stevens. Explore the table further to examine your county’s rate of opioids dispensed and how that compares to the state and your region.

Source

MN Prescription Monitoring Program (PMP)

Description: In 2009, Minnesota Statutes required the Board of Pharmacy to develop and maintain a database of controlled substance prescriptions for the purpose of promoting public health and welfare by detecting abuse, misuse, and diversion of controlled substance prescriptions. The goal of the PMP is to assist in improving patient care and reducing the misuse of controlled substances. In mid-2014, a change in Minnesota Statutes became effective which allowed the PMP to participate in the interstate exchange of data with prescribers and pharmacists in other states. Prior to July 1, 2014, dispensers were only required to report Minnesota schedule II-IV controlled substances to the Minnesota PMP database. Effective July 1, 2014, dispensers were required to report schedule V controlled substances as well as butalbital and tramadol.

Geographic level data are available: state, county

Strengths: PMPs have proven to be effective in reducing prescription drug abuse, misuse, and diversion, assisting in identifying inappropriate prescribing or dispensing, and aiding in drug investigations, amongst other efforts. The PMP includes information on all schedule II-V, butalbital, and tramadol dispensed in Minnesota. It also actively shares data with 22 states to better monitor prescriptions because of the ease with which it is possible to obtain prescriptions in multiple states. The use of Controlled Substance Insight Alerts also informs prescribers and pharmacists when a patient, in their care, has exceeded a set threshold that may indicate the patient is at risk or may be doctor shopping.

Limitations: Prescription data in the PMP are only as accurate as the records submitted by the dispensers. Prescribers are not required to utilize the PMP; a law set to go into effect July 1, 2016 mandates that prescribers create a PMP account, but that law does not cover PMP utilization. Not all licensed prescribers and pharmacists need access to the PMP to perform their job functions. For this reason, it is unlikely that 100% of prescribers and pharmacists licensed and practicing in Minnesota would obtain and utilize access to the PMP, unless the law changed requiring them to do so. It is also difficult to track the impact the PMP may be having on an individual, prescriber, or public health because of data privacy considerations.

Note: MN's Prescription Monitoring Program (PMP) is generally called a Prescription Drug Monitoring Program or PDMP.

Resources

Prescription Monitoring Queries

Minnesota Opioid Prescribing Guidelines
Minnesota’s opioid prescribing guidelines (PDF) provide a framework for safe and thoughtful opioid prescribing for pain management. In partnership with the medical community, the Minnesota Department of Human Services and the Minnesota Department of Health developed the guidelines for clinicians who manage pain in primary care and specialty outpatient settings. The opioid prescribing guidelines were developed by the Opioid Prescribing Workgroup (OPWG).

MN Prescription Monitoring Program (PMP)
PMP annual reports and monthly data from 2013-2017

MN Prescription Monitoring Program Educational Sessions
The MN Prescription Monitoring Program is offering a series of provider educational sessions in Bemidji, St. Cloud, Duluth, and the Twin Cities at no cost. Sign up for one today!

Mike's Rx Awareness Story

 

Electronic Prescribing (E-Prescribing) Mandate
Two new e-prescribing resources are now available on the Minnesota Department of Health’s e-prescribing webpage. The FAQ for e-Prescribing of Controlled Substances (EPCS) provides general information on EPCS and the Minnesota e-Prescribing Mandate Factsheet summarizes the Minnesota Statutes 62J.42 that requires the e-prescribing of all prescriptions including controlled substances. EPCS helps to reduce fraud and abuse of controlled substance and is one way to use e-health to prevent and respond to the opioid misuse and overdose.

PMP Registration
PMP Access Request Forms for prescribers, pharmacist, delegates, corners, and coroner delegates

MN Statute 152.02
List of Minnesota scheduled controlled substances

The PEW Charitable Trusts Prescription Drug Monitoring Programs Report
Report that outlines eight strategies to maximize the efficacy of Prescription Drug Monitoring Programs (PDMPs)

Center for Disease Control Prescribing Opioid for Chronic Pain
CDC Guideline for prescribing opioids for chronic pain

CDC Opioid Prescribing Clinical Tools
Clinical tools for prescribing opioids for chronic pain, including a mobile app for calculating MME

Institute for Clinical Systems Improvement (ICSI) Pain Guidelines: Assessment, Non-Opioid Treatment Approaches and Opioid Management
ICSI Guideline for pain management

Minnesota Medical Association Opioid Lecture Series
The Minnesota Medical Association (MMA), the Steve Rummler Hope Network (SRHN) and the University of Minnesota Medical School developed a lecture series designed for physicians, resident, and medical students who are looking for education on pain, opioids, and addiction.

New York American College of Physicians Free CME for Managing Pain and Opioid Use
Free continuing medical education for managing pain and opioid use, offered by the NY American College of Physicians

Stop Talking Dirty
Abstract for Stop Talking Dirty, and article from The American Journal of Medicine, that addresses the use of the words “clean” and “dirty” in chemical health care

Motivational Interviewing: SAMHSA Clinical Practice Tools
Resources and webinars on Motivational Interviewing, a tool for evoking a patient’s desire, ability, and need to change, as well as enhancing their intrinsic motivation to change

Academic Detailing
Webinar on the use of academic detailing, or peer-to-peer education, to cut opioid-related emergency visits in half in San Francisco

Arthur’s Story
You Tube video on one patient’s recovery from chronic pain using yoga

Parity Complaint Registry and Appeal Resource
National registry to track, study, and report on parity violations regarding the Mental Health Parity and Addiction Equity Act (MHPAEA). View of a video made by The Kennedy Forum called The New Frontier of Mental Health and Addiction. 

 

Prevention

When it comes to prescribing practices, some upstream actions and promising practices include:

• Opioid Prescribing Guidelines: The Opioid Prescribing Workgroup (OPWG) developed acute, post-acute, and chronic pain prescribing guidelines – Opioid Prescribing Guidelines.
• Provider Messaging Campaign: The Opioid Prescribing Improvement Program (OPIP) is developing a peer-to-peer prescriber educational campaign (ETA Summer 2018) that addresses how to talk about the long-term risks of opioids, how to introduce the idea of a taper and/or chemical health treatment for a patient on chronic opioids, and other clinical practices related to pain management and opioid prescribing.
• Co-Prescribing Naloxone: Some states have passed legislation that mandates co-prescribing of naloxone with all opioid prescriptions. Other states have set certain circumstances (e.g. MME over 50, benzo/opioid prescriptions) when a naloxone prescription would be required with an opioid prescription.
• Informed Decision Making: A JAMA study from December 2017 noted that 40% of people are sent home with opioids “just in case”, even when the patient was not using opioids upon release from the hospital. Patients can play an active role in decision-making about their care, including how to address pain management. A simple tool that patients can use is called the BRAIN acronym. When being offered a particular interventions, ask yourself what are the Benefits, Risks, Alternatives, What is my Intuition telling me?, and What if I say “No, not now?”. The BRAIN acronym can be helpful to think through options for pain management or selecting a treatment approach.

The PEW Charitable Trust published an extensive report on evidence-based practices to optimize prescriber use of the Prescription Monitoring Program (PMP), including:

• Prescriber use mandates
• Delegation
• Unsolicited reports
• Data timeliness
• Streamlined enrollment
• Educational and promotional initiatives
• Health information technology (IT) integration
• Enhanced user interfaces

Read more about the PMP recommendations at The PEW Charitable Trusts Prescription Drug Monitoring Programs Report.

Please visit the Prevention tab under each indicator for additional upstream actions and promising practices.

Analysis

Oxycodone, methadone, morphine, and hydrocodone account for the greatest number of grams in retail drug purchases in Minnesota in 2016. In 2016, the total amount of drug retail purchases of prescription opioids in Minnesota was 4.9 kilograms of morphine equivalent per 10,000 persons or 494 morphine equivalent per capita. This corresponded to 2710 kg of morphine equivalent sold in Minnesota.

Total opioid sales to in morphine kilogram equivalent per 10,000 population in Minnesota increased from 2007 to 2012. Since 2014, total opioid sales have declined. Minnesota has had far fewer total opioid sales than the U.S. in 2016.

The total number of drug arrests in 2017 was 2,875. There were 356 arrests for heroin and 490 arrests for prescription drugs. In 2017, the amount of heroin seized was 19,173 grams, while the number of doses of prescription drugs seized was 214,429. From 2016 to 2017, the number of arrests for heroin and prescription drugs decreased, while the number of seizures increased. In 2017, there were fewer grants funding the Violent Crime Enforcement Teams. In other words, there are fewer people working on drug seizures and violent crime enforcement. The reduction in drug seizures and arrests may be due to less funding of teams rather than an actual decrease in the total number.

Source

Drug Enforcement Administration (DEA) Automation of Reports and Consolidated Orders System (ARCOS)

Description: Although not a direct indicator of opioid abuse, trends in total sales of prescription opioids can provide insight into possible overuse, diversion and/or abuse. Retail drug purchases (which include purchases by weight by pharmacies, hospitals, practitioners, narcotic treatment programs, and teaching institutions) of prescription opioids have been increasing nationally. In 2001, there were 3.1 kilograms of morphine equivalent sold per 10,000 population. This more than doubled to 8.5 kilograms of morphine equivalent sold per 10,000 population in 2014. The kilograms of morphine equivalent sold per 10,000 population ranged from 4.8 to 14.8 among all states in 2014.

Geographic level data are available: National, state

Strengths: Retail drug purchases included purchases by weight by pharmacies, hospitals, practitioners, narcotic treatment programs, and teaching institutions. The quantity of opioid prescription drugs were expressed in morphine kilogram equivalent per 10,000 population per year, for the year 2016. Trends in sales of prescription opioids can provide insight into possible overuse, diversion, and/or abuse.

Limitations: This indicator cannot distinguish between prescriptions issued for necessary pain relief and prescriptions issued for other reasons. The optimal amount of prescribed MMEs of opioid drugs per capita is not known. Reducing overall consumption of opioid drugs too low could mean that some people are not obtaining needed pain relief. The data reported by the U.S. DEA reflect the distribution of prescription opioids to pharmacies, not actual prescriptions written or filled, medications taken, or individual users.

Department of Public Safety (DPS) Violent Crime Enforcement Teams (VCET)

Description: Drug arrests and seizures that are completed by the Violent Crime Enforcement Teams are submitted to the Minnesota Department of Public Safety. Information includes the number of arrests for sale or possession of drugs, the type of drug involved in the arrest, race or ethnicity, age, gender, the type of drug seized, as well as prevention and training activities.

Geographic level data are available: state

Strengths: These data provide a picture of the drug activity that has been observed through arrests and seizures by the Minnesota Department of Public Safety. The data are updated quarterly and shared with the Minnesota Department of Health in a timely manner. These data provide another layer of information regarding the type of drug arrests that are occurring and the type of drugs involved.

Limitations: These data are limited in their ability to identify emerging drug trends, and may not accurately represent drug use patterns. The decrease in arrests and seizures in the first quarter of 2017 likely reflects two fewer grants to Violent Crime Enforcement Teams, which makes trends in these data difficult to interpret as funding changes.

Resources

Total Opioid Sales in Morphine Kilogram Equivalents

Managing Unwanted Medications: Safe Disposal Drop-Box Locations
Locations for and explanation of safe disposal of prescription medications.

Safe Disposal Drop-Box Fact Sheet
The collection requirements for law enforcement agencies and pharmacies are different. This fact sheet will discuss the collection requirements for pharmacies.

DEA Diversion Control Division
Reporting illicit pharmaceutical activities and prescription misuse online.

Office of Justice Programs Violent Crime Coordinating Council (VCCC)
The 2010 MN Legislature established the Violent Crimes Coordinating Council to provide guidance related to the investigation and prosecution of gang and drug related crime (2016 VCCC Annual Report and meeting minutes are available).

Drug and Violent Crime Enforcement Team (VCET) Task Forces (PDF)
Overseen by the VCCC, these multi-jurisdictional task forces address narcotics, gang and related violent crime. Their goal is to increase the identification and arrest of serious law violators and enhance the amount of law enforcement expertise available statewide for complex investigations that cross jurisdictional boundaries. There are currently 23 funded task forces that oversee 70 counties and are comprised of over 200 investigators.

VCET Commanders List (Word)
Alphabetical listing of each commander for the 23 task forces in Minnesota.

MN Statute 152.021
Sale and possession of controlled substances.

CMS Guide for Prescriber’s Role in Preventing the Diversion of Prescription Drugs
Twelve clinical practices that can minimize drug diversion.

MDH Drug Diversion Prevention
This site includes a final report from Minnesota Controlled Substance Diversion Prevention for preventing diversion within hospitals and nursing homes.

Fentanyl Safety Recommendations for First Responders (PDF)
Scientific, evidence-based recommendations to prevent exposure to fentanyl

Harm Reduction Coalition
Information and resources about harm reduction include the eight principles of harm reduction and best practice guidelines for harm reduction

Minnesota Pharmacy Syringe/Needle Access Initiative
Information about and list of all pharmacies participating in syringe access program

MN Syringe Service Program Calendar
A listing of hours and locations for Syringe Service Programs in MN. 

A Guide to Establishing Syringe Services Programs in Rural At Risk Areas
A toolkit created by the Comer Family Foundation in response to the CDC report that identified 220 counties that are vulnerable to outbreaks of HIV and hepatitis C

Shootin’ with Care: Safer Injection (Part 1)
Educational program for injection drug users (Note: please use Firefox or Chrome browsers to view)

Shootin’ with Care: Safer Injection (Part 2)
Educational program for injection drug users (Note: please use Firefox or Chrome browsers to view)

Don’t Let Them Sleep it Off
Public service announcement and media campaign in Sarasota to educate the community to attempt to rouse, or wake up, people who are found unconscious

Prevention

When it comes to harm reduction, some of the upstream actions and promising practices include:

• Safe Disposal: Eighty percent of people who use heroin, started by using, and then misusing, prescription medications. When first starting to use prescription opioids, research shows that about 50% of people obtain the prescriptions from a family member or friend who is helping them out; only 15% of people obtained the prescriptions by buying them off the street with the intent to get high. Sources of prescription medications come from (1) medications prescribed to a patient, (2) unused medications prescribed to family members or friends, (3) legally prescribed medications now sold on the street, and (4) illegally manufactured prescription medications from pill mills. Ninety percent of people who were prescribed a prescription medication for an acute injury do not use the entire bottle. This results in millions of unused pills that now have become a viable source for diversion. Unused pills in a home are an overdose risk for children and pets. Some of the upstream interventions related to preventing diversion include: (1) providing carbon-activated pouches with all controlled substance prescription medications for safe at-home disposal and (2) providing incentives for safe disposal of unused medications.
• Real-time alerts for fentanyl-laced products: Communities are exploring the idea of using real-time alerts for fentanyl-laced products. In cities throughout the United States, there have been large number of overdoses within short periods of time, most likely caused from a single source of fentanyl-laced heroin or counterfeit prescription medications. The idea is to create an amber-alert-style of message that could go out to and from law enforcement, EMS, medical professionals, and people who use heroin or buy prescription opioids outside of a health system.
• Supervised Injection Sites: There are over 100 supervised injection sites in the world. There has not been one opioid overdose death associated with use at any of the injection sites. When law enforcement encounter a person on the street, in a park, or other public venue, now they have a place to refer people; this has reduced public injecting. Inside the supervised injection site, people can get help with vein access from a medical professional; this has reduced the harms associated with collapsed veins and scar tissue formation. The injection sites have supplies available such as sterile water, cotton, syringes, and scales for measuring; this has helped to regulate dosage and decrease harms associated with sharing needles and supplies. At the supervised injection sites, drug sharing or drug splitting is not allowed. There are rooms for people to stay in where they are observed for overdose by a medical professional.
• Fentanyl testing strips: At Insite, a supervised injection site in the Bronx, they offer fentanyl testing strips so IV drug users can test for the presence of fentanyl in their heroin stash. Many users think that their dope is pure or raw, and have been surprised by the testing results. Fentanyl testing strips have allowed users to warn other people who use heroin about the presence of fentanyl. The principle is simple: fentanyl testing strips provide knowledge and information about what is being put in their body. However, fentanyl testing strips have not been found to reduce use. Most of the people who attend Insite are daily IV drug users; their main concern is running on empty, when the physical symptoms of opioid withdrawal kick in. When surveys have been returned, they have provided information about which brands might be more dangerous and what a tainted batch looks like or smells like during use.
• Needle Vending Machines: At the height of use, people may use upwards of 15 needles a day. Even within communities that have needle exchanges, the availability of needles does not meet the need. Las Vegas launched the first clean needle vending machine to measure the effectiveness of automated dispensing of clean needles for IV drug users. Clean needles are known to promote public health, by reducing the exposure to infectious diseases such as HIV and Hepatitis C (HCV). The vending machines also carry wound cleaning kits and safe sex kits. Users register, receive a swipe card and unique identification number, and can receive up to two kits per week. The vending machines are located in the HIV-prevention office and available 24/7. Staff are available during the day to answer questions and/or to provide referrals to detox, treatment, and support groups. In the first month of implementation, the needle vending machines were mostly used during the night, when no other needle exchange is open.
• Seeing Track Marks: The ability of family and friends to identify track marks is one way to detect use, and provide an opportunity for early intervention. Most people are using IV drugs for long periods of time in isolation, before family and friends become aware of the person’s use. Heroin, cocaine, methamphetamines, prescription stimulants, and prescription opioids can be injected into the bloodstream through a vein. Users prefer discrete injection sites. Most users start by shooting up in their forearms. When there is scarring, inflammation at the injection site, damaged or collapsed veins, lesions, or bruising, access to those veins becomes extremely painful or impossible. Users will move to other areas of the body such as neck, groin, hands, feet, or face. The more visible the injection site, the more likely a user is going to try to cover it up with clothing, make-up, or tattoos.

Please visit the Prevention tab under each indicator for additional upstream actions and promising practices.

Analysis

From 2012 to 2016, the number of diagnoses of neonatal abstinence syndrome (NAS) in children less than one year of age increased from 236 in 2012 to a peak of 479 in 2015, and then decreased to 402 in 2016; the corresponding rates also increased from 35.9 per 10,000 live births in 2012 to a peak of 71.4 per 10,000 live births in 2015, and then decreased to 60.0 per 10,000 live births in 2016. The increase in the number of cases likely reflects both an increase in the actual number of diagnoses of NAS, as well as better recognition and diagnosis of NAS among children less than one year of age.

From 2012 to 2016, the highest rate of neonatal abstinence syndrome (NAS) was in the Northwest and Northeast regions of the state. The lowest rates of NAS were in the Southwest and South Central regions of the state. Overall, the state rate for 2012 to 2016 was 55.2 per 10,000 live births.

The Centers for Disease Control and Prevention (CDC) developed a methodology to examine the potential for rapid dissemination of hepatitis C virus (HCV) associated with injection drug use. The statistical model takes into consideration county-level data on factors associated with injection drug use. The CDC analysis highlighted the top 220 counties in the U.S., of which none were in Minnesota. In order to understand the risk in Minnesota, this analysis was replicated with Minnesota county data. The results showed that counties in Northeast and North Central Minnesota were the most vulnerable to rapid dissemination of HCV associated with injection drug use.

In 2014, the rate of hospital-treated mental disorders for three groups of mental disorders varied by age group. The hospital-treated rate for all mental disorders, except drug or alcohol induced disorders, as well as mood and depressive disorders peaked in 15-24 year olds. The hospital-treated rate of schizophrenic disorders was much lower, and the highest rate was in the 25-34 year age group. Following the peak, rates for hospital-treated mental disorders decreased for all age groups, except in individuals greater than 74 years of age for all mental disorders, except drug or alcohol induced disorders.

Source

Minnesota Hospital Discharge Database

Description: Data for neonatal abstinence (NAS) come from the Minnesota Hospital Discharge Database provided by the Minnesota Hospital Association. Data are provided quarterly to the Minnesota Department of Health. These data include all inpatient and emergency department hospital treatments at acute care, non-federal in-state hospitals and some border hospitals. Stand-alone psychiatric facilities are not included; however, psychiatric admissions within a hospital are included. There are 147 hospitals in Minnesota, including non-acute care facilities; 137 are members of the Minnesota Hospital Association; 135 are included in the all-age injury hospital discharge database at the Minnesota Department of Health. There are a small number of hospitals who are not members of the Minnesota Hospital Association that will not be in the data.

Geographic level data are available: State, trauma regions, EMS regions, county of residence, ZIP Code of residence

Strengths: The data represent a majority of hospitalizations for NAS in Minnesota, regardless of the insurance carrier or payer. The data are also de-duplicated prior to analysis, which results in the removal of counting an individual hospitalization more than once.

Limitations: Hospital discharge data are primarily intended for billing purposes, not public health surveillance. The data also do not currently contain race or ethnicity. The transition to ICD-10-CM in the final quarter of 2015 (October – December 2015) makes comparisons inaccurate to previous years. Data for 2015 should be interpreted cautiously and trends should not include 2015 data because of the transition to ICD-10-CM.

Resources

Rates of Neonatal Abstinence Syndrome (NAS)

Minnesota Counties at Higher Risk for HCV Dissemination

Get Tested
National database of HIV, STD, and Hepatitis testing locations

MDH STD/HIV Partner Services Program
Informing sexual partners of positive STD or HIV test results is a sensitive and private way

Substance Use during Pregnancy and Substance Exposed Infants
From Children’s Minnesota, this site includes an information sheet on opioid use during pregnancy, as well as an information sheet on neonatal abstinence syndrome (NAS)

Neonatal Abstinence Syndrome (NAS) Toolkit
Toolkit for the identification, screening, and treatment of NAS, developed by the MN Hospital Association

Clinical Guidance for Treating Pregnant and Parenting Women with Opioid Use Disorder and Their Infants
Guide for health care professionals seeking to improve outcomes for women and infants through the use of accessible, standard approaches to care.

Neonatal Abstinence Syndrome (NAS) Data Brief
Statewide and county trends in neonatal abstinence syndrome, 2012-2016

Addressing Viral Hepatitis in People with Substance Use Disorders
Quick guide including screening, evaluation, clinical decision making, treatment, and counseling of viral hepatitis for clinicians and administrators from SAMHSA

HepVu
Interactive maps that visualize Hepatitis C across the country

AIDSVu
Interactive maps that visualize HIV across the country

Harm Reduction Coalition
Information and resources about harm reduction include the eight principles of harm reduction and best practice guidelines for harm reduction

Minnesota Pharmacy Syringe/Needle Access Initiative
Information about and list of all pharmacies participating in syringe access program

Behavioral Health Trends in the United States
Results from the 2014 National Survey on Drug Use and Health, including illicit drug use and co-occurring mental health and substance use disorders

National Alliance on Mental Illness
Resources for support groups, helpline, and addressing stigma

Zero Suicide
Strategies and tools for the Zero Suicide model for suicide prevention in health and behavioral health care systems

Suicide Prevention Resource Center
Resources for suicide prevention including best practices, terms, risk and protective factors, warning signs, fact sheets for specific populations, and strategic planning frameworks

Minnesota Family Planning & STD Hotline
Provides the entire state of Minnesota with reliable, medically accurate, and confidential information via phone, text and web chat.

Prevention

When it comes to co-occurring disorders, some upstream actions and promising practices include:

• Establishing partner notification services for infectious disease including syphilis
• Educating small sexual networks about containing the spread of sexually transmitted infections
• Monitoring infectious disease treatment retention, and providing services until completion
• Early detection of serious and persistent mental illness to prevent self-medication with illicit substances
• Streamlining Health Care Home (HCH) and Behavioral Health Home (BHH) services
• Aligning SAMHSA and CDC funded projects within clinical settings
• Integrating medical, mental, dental, sexual, and chemical health care
• Implementing comprehensive and routine opt-out HIV, hepatitis B, hepatitis C, syphilis, and TB testing, along with hepatitis A/hepatitis B immunizations for all people entering chemical health treatment centers

Neonatal abstinence syndrome (NAS)/neonatal opioid withdrawal syndrome (NOWS) occurs when infants experience withdrawal symptoms after being exposed to prescription and/or illicit opioids in the womb. Prevention strategies for NAS/NOWS include:

• Access to and use of preconception health that includes education around prescription and illicit drug use during pregnancy
• Increased substance use screening for women (e.g. SBIRT services) who are or wish to become pregnant
• Providing pregnant women with Medication for Addiction Treatment (MAT) when needed to minimize NAS/NOWS symptoms in the infant after birth; suboxone, in particular, has been associated with shorter hospital stays for infants, higher rates of breast-feeding upon leaving the hospital, and higher rates of sustained long-term recovery for moms

Please visit the Prevention tab under each indicator for additional upstream actions and promising practices.

Analysis
Analysis of ACEs data coming Spring 2019.

Source
Analysis of ACEs data coming Spring 2019.

Resources

Power of Protective Factors for Minnesota Youth: Findings from the 2016 Minnesota Student Survey (PDF)
Results from a survey of Minnesota youth about the effects of protective and risk factors on health outcomes

MDH Health Report: Advancing Health Equity in Minnesota (PDF)
A Report to the Legislature that includes recommendations for advancing health equity in Minnesota

MDH Center for Health Equity
Resource Library for Advancing Health Equity in Public Health

SAMHSA Adverse Childhood Experiences
Information about adverse childhood experiences and how they act as a risk factor for developing substance use disorders.

CDC Social Determinants of Health
Information about sources of data, programming, policy resources, and tools for addressing social determinants of health

Healthy People 2020 Social Determinants of Health
Resources around economic stability, education, health and health care, neighborhood and built environment, and social and community context from the Office of Disease Prevention and Health Promotion

WHO Commission on Social Determinants of Health
Final Report from the World Health Organization about actions to close the gap of social determinants of health

SAMHSA Eight Dimensions of Wellness
Framework from SAMHSA for considering holistic wellness

Prevention

When it comes to prescribing practices, some upstream actions and promising practices include:

• Health in All Policies (HiAP): integrate and articulate health considerations in policy making across sectors, at all levels, and for all communities and people
• Provide leadership for advancing health equity: engage state, tribal, and local government and encourage the adoption of a health in all policies (HiAP) approach
• Make health equity an emphasis: advancing health equity is the work of every person within an organization who has any impact on people, programs, communities, or policies
• Strengthen the collection and analysis of data to advance health equity: collect and analyze health data by population groups, including diversity within population groups, LGBTQ data, and data on the social and economic factors that create health

Please visit the Prevention tab under each indicator for additional upstream actions and promising practices.