The recreational use of drugs and other substances is an emerging and important public health threat. In Minnesota, there was a 16% increase in fatal drug overdoses between 2015 and 2016. Similarly, non-fatal emergency department (ED) visits for opioid overdoses have been increasing steadily over the past 10 years. Since 2010, there have been at least four clusters of synthetic drug use in various communities in Minnesota. The burden that drug overdoses impose on health care systems is difficult to quantify. Many ED visits attributed to recreational drug use do not have a diagnosis of drug overdose, but have diagnoses of symptoms and signs related to substance abuse (e.g., altered mental status, acute respiratory failure, etc.). As such, these visits are not readily identified from typical data sources.
During the epidemiologic investigation of one of the aforementioned clusters, epidemiologists from the Minnesota Department of Health (MDH) discovered that identifying cases through chart review was impossible, as a wide variety of ICD codes were used. This cluster highlighted the need for a surveillance system to identify patients who present to the ED and/or are hospitalized for drug use or substance abuse.
In collaboration with key partners, MDH designed the Minnesota Drug Overdose and Substance Abuse Pilot Surveillance System (MNDOSA). This innovative surveillance system aims to: (1) determine the burden of overdose and substance abuse in Minnesota hospitals, (2) identify clusters of drug overdoses in near real time to provide situational awareness to stakeholders, (3) identify substances causing atypical clinical presentations, clusters, and severe illness and/or death, and (4) describe at-risk populations in order to focus and guide prevention efforts. MNDOSA is unique and novel as it collects real-time data rather than relying on data sources that have long delays in reporting, allowing for a near real-time response and notification of stakeholders.
This surveillance system combines reporting of drug overdose cases at three pilot hospitals, enhanced toxicology testing of clinical specimens, medical record reviews for a subset of patients, and the utilization of public health codes in medical records to monitor trends in drug and substance abuse and overdose in Minnesota. Active reporting includes real-time reporting to MDH of ED and in-patient admissions at the participating hospitals where the principal diagnosis is attributed to the recreational use of one or more of the following: Schedule I drugs, opioids (including prescription opioids, fentanyl or fentanyl analogs), synthetic, non-prescription drugs, prescription drugs, drug combinations, natural substances for recreational purposes, and other substances, including inhalants. ED visits and/or hospitalizations attributed to alcohol use alone are excluded from surveillance. Comprehensive data is abstracted from medical records for a subset of patients.
Clinical specimens for a small number of patients are submitted to the MDH Public Health Laboratory for enhanced toxicological testing. This testing is necessary because clinical specimens are often not obtained from non-fatal drug overdose patients in the ED. Additionally, hospital laboratory panels do not detect many of the new, synthetic drugs. The MDH Laboratory has the capacity to detect a vast array of prescription, illicit, and designer drugs. Laboratory results are used for surveillance purposes only, and the results will enhance understanding of the drugs/substances circulating in Minnesota.
In addition to active reporting, this surveillance incorporates an informatics-based, passive approach. Public health codes will be assigned to patients’ medical record for ED visits and hospitalizations attributed to the recreational use of the aforementioned drugs/substances, allowing MDH to monitor trends and patterns in drug/substance use and overdose in Minnesota.
Surveillance started in November of 2017 with plans to continue until December 2020, at which time the feasibility of continued surveillance will be assessed. MNDOSA is supported in part by funding from CSTE. The lessons learned thus far include: