CDC’s Drug Overdose Surveillance and Epidemiology (DOSE) System

The CDC DOSE system was developed to analyze data from syndromic surveillance systems to rapidly identify outbreaks and provide situational awareness of changes in drug overdose-related emergency department (ED) visits at the local, state, and regional level. DOSE leverages timely ED syndromic data captured by health departments to gather aggregate data on ED visits involving suspected all drug, all opioid, heroin, and all stimulant overdoses. Aggregate data include demographic characteristics of those who overdosed, such as sex, age, and county of patient residence. Jurisdictions share their data with CDC as frequently as every two weeks either by uploading data using a secure server or allowing DOSE staff access to their data in CDC’s National Syndromic Surveillance Program’s (NSSP) BioSense platform. The number of jurisdictions included in the calculations of monthly and annual percent change estimates in rates will vary over time. Comparisons between jurisdictions should not be made because of variations in data quality, completeness, and reporting across jurisdictions.

Syndrome Definition

A hallmark of the DOSE System is the use of standardized syndrome definitions for suspected all drug, all opioid, heroin, and all stimulant overdoses. All definitions draw from multiple fields within ED data to classify visits as overdose-related.

We use diagnostic codes medical professionals use for clinical diagnosis and insurance billing purposes, specifically, International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes, International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes, and SNOMED (Systematized Nomenclature of Medicine — Clinical Termsexternal icon) codes. Where manner of injury is defined, only diagnosis codes for “unintentional” or “undetermined” intent drug poisoning are included in the DOSE standardized syndrome definitions.

Although most diagnostic codes provide sufficient indication of a suspected drug overdose, another subset of diagnostic codes specific to opioid drug use, abuse, and dependence is less specific; therefore, when these are the only codes present, additional information is needed for the ED visit to be captured as a suspected drug overdose.

We use the free text field called “chief complaint,” which represents the purpose of an ED visit, for example, “Patient was found unresponsive. EMS provided Narcan and patient said took heroin.” To be included as an overdose-related ED visit based on chief complaint, records must include two components: 1) Text indicating an overdose or poisoning and 2) Text indicating the involvement of a drug or a diagnostic code for opioid use, abuse, and dependence. Common misspellings of key search terms, for example, “herion” instead of “heroin,” are also included.

Please click on each of the drug overdose indicators below to see the full definition:

Variable Automatic inclusion? Specific terms
Chief complaint and discharge diagnosis search terms for suspected all drug overdose
Inclusions
Discharge Diagnosis – ICD-9-CM poisoning Yes 960-979; E850-E858; and E980.0-E980.5
Discharge Diagnosis – ICD-10-CM poisoning Yes T36-T50 (only 1 and 4 for intent and A for first encounter; no underdosing or adverse effect)

For T36.9, T37.9, T39.9, T41.4, T42.7, T43.9, T45.9, T47.9, and T49.9, a 5th character; for all others, a 6th character

Discharge Diagnosis – ICD-10-CM opioid abuse/dependence/use with intoxication Yes F11.12, F11.120, F11.121, F11.122, F11.129, F11.22, F11.220, F11.221, F11.222, F11.229, F11.92, F11.920, F11.921, F11.922, F11.929 (also included terms with no period, e.g., “F1112”)
Discharge Diagnosis – SNOMED Yes 295121001, 295597003, 295487009, 295334008, 295313001, 295593004, 295799003, 295117008, 295495008, 295332007, 295808006, 295123003, 295587007, 295314007, 295134000, 295910009, 296295001, 296412004, 296529003, 296334003, 296921006, 296513006, 296389000, 296845006, 296499009, 296922004, 296825003, 296943003, 296896008, 296853003, 296974001, 296450005, 296478006, 296402006, 296970005, 296509004, 296503003, 296425007, 296811004, 296948007, 297006008, 297094003, 297065005
Chief complaint – narcan or naloxone Yes Naloxone (narcan, evzio)
Chief complaint – overdose term Yes Overdose (overdose, overdoes, averdose, averdoes, over does, overose)
Chief complaint – overdose term No, must use in combination with drug term Poisoning (poison)
Nodding off
Snort
Ingestion (ingest, injest)
Intoxication (intoxic)
Unresponsive (unresponsiv)
Loss of consciousness (syncopy, syncope)
Shortness of breath (SOB), short of breath
Altered mental status (AMS)
Chief complaint – drug term No, must use in combination with overdose term Drug, pill, poly drug/substance
Stimulants – Cocaine, Amphetamine, Methamphetamine…
Benzodiazepines – Alprazolam, Clonazepam, Diazepam, Lorazepam, Xanax….
Hallucinogens – Phencyclidine (PCP), MDMA, Ecstacy, Lysergic acid diethylamide (LSD)…
Opioids – Buprenorphine, Codeine, Fentanyl, Heroin, Hydrocodone, Hydromorphine, Methadone, Morphine, Oxycodone, Oxymorphone, kratom, loperamide…
Marijuana, cannabinoids and synthetic cannabinoids…
Cathinones or bath salts…Ketamine…Gabapentin…Gamma hydroxybutyrate (GHB)…Sleep sedatives
Discharge Diagnosis – ICD-10-CM opioid abuse/dependence/use No, must use in combination with overdose term F11.10, F11.90, F11.20
Exclusions
Chief complaint Exclude Requests for drugs/drug-seeking behaviors
Receiving drugs for care (e.g., morphine provided for pain)
Detoxification
Withdrawal
Denying drug use
Denying loss of consciousness or shortness of breath, etc.
Variable Automatic inclusion? Specific terms
Chief complaint and discharge diagnosis search terms for suspected all opioid overdose
Inclusions    
Discharge Diagnosis – ICD-9-CM poisoning Yes 965.00, 965.01, 965.02, 965.09, E850.0, E850.1, E850.2 (also included terms with no period, e.g., “96500”)
Discharge Diagnosis – ICD-10-CM poisoning Yes T40.1X1A, T40.1X4A, T40.0X1A, T40.0X4A, T40.2X1A, T40.2X4A, T40.3X1A, T40.3X4A, T40.4X1A, T40.4X4A, T40.601, T40.604, T40.691, T40.694 (also included terms with no period, e.g., “T401X1A”)
Discharge Diagnosis – ICD-10-CM opioid abuse/dependence/use with intoxication Yes F11.12, F11.120, F11.121, F11.122, F11.129, F11.22, F11.220, F11.221, F11.222, F11.229, F11.92, F11.920, F11.921, F11.922, F11.929 (also included terms with no period, e.g., “F1112”)
Discharge Diagnosis – SNOMED Yes 295174006, 295175007, 295176008, 295165009, 242253008, 297199006, 295213004
Chief complaint – narcan or naloxone Yes Naloxone (narcan, evzio)
Chief complaint – overdose term No, must use in combination with opioid term Poisoning (poison)
Overdose (overdose, overdoes, averdose, averdoes, over does, overose)
Nodding off
Snort
Ingestion (ingest, injest)
Intoxication (intoxic)
Unresponsive (unresponsiv)
Loss of consciousness (syncopy, syncope)
Shortness of breath (SOB), short of breath
Altered mental status (AMS)
Chief complaint – opioid term No, must use in combination with overdose term opioid, opiod, opoid, opiate, opate, opium, opium, opum, heroin, herion, heroine, HOD, speed ball, speedball, dope, methadone, suboxone, oxyco, oxy, oxyi, percoc, vicod, fent, hydrocod, morphin, codeine, codiene, codene, oxymor, dilaud, hydromor, tramad, suboxin, buprenorphine, and other common opioid brand and generic names
Discharge Diagnosis – ICD-10-CM opioid abuse/dependence/use No, must use in combination with overdose term F11.10, F11.90, F11.20
Exclusions
Chief complaint Exclude Requests for drugs/drug-seeking behaviors
Receiving drugs for care (e.g., morphine provided for pain)
Detoxification
Withdrawal
Denying drug use
Denying loss of consciousness or shortness of breath, etc.
Variable Automatic inclusion? Specific terms
Chief complaint and discharge diagnosis search terms for suspected heroin overdose
Inclusions
Discharge Diagnosis – ICD-9-CM poisoning Yes 965.01, E850.0 (also included terms with no period, e.g., “96501”)
Discharge Diagnosis – ICD-10-CM poisoning Yes T40.1X1A, T40.1X4A (also included terms with no period, e.g., “T401X1A”)
Discharge Diagnosis – SNOMED Yes 295174006, 295175007, 295176008
Chief complaint – overdose term No, must use in combination with heroin term Poisoning (poison)
Overdose (overdose, overdoes, averdose, averdoes, over does, overose)
Nodding off
Snort
Ingestion (ingest, injest)
Intoxication (intoxic)
Unresponsive (unresponsiv)
Loss of consciousness (syncopy, syncope)
Shortness of breath (SOB), short of breath
Altered mental status (AMS)
Chief complaint – heroin term No, must use in combination with overdose term Heroin, herion, heroine, HOD, speedball, dope
Exclusions
Chief complaint Exclude Detoxification
Withdrawal
Denying drug use
Denying loss of consciousness or shortness of breath, etc.
Variable Automatic inclusion? Specific terms
Chief complaint and discharge diagnosis search terms for suspected all stimulant overdose
Inclusions
Discharge Diagnosis – ICD-9-CM poisoning Yes 969.70, 969.71, 969.72, 969.73, 969.79, 970.0, 970.81, 970.89, 970.9, E854.2, E854.3, E855.2 (also included terms with no period, e.g., “97080”)
Discharge Diagnosis – ICD-10-CM poisoning Yes T40.5X1A, T40.5X4A, T43.601A, T43.604A, T43.611A, T43.614A, T43.621A, T43.624A, T43.631A, T43.634A, T43.641A, T43.644A, T43.691A, T43.694A (also included terms with no period, e.g., “T405X1A”)
Discharge Diagnosis – SNOMED Yes 296321004, 441527004, 296290006, 61803000
Chief complaint – overdose term No, must use in combination with stimulant term Poisoning (poison)
Overdose (overdose, overdoes, averdose, averdoes, over does, overose)
Nodding off
Snort
Ingestion (ingest, injest)
Intoxication (intoxic)
Unresponsive (unresponsiv)
Loss of consciousness (syncopy, syncope)
Shortness of breath (SOB), short of breath
Altered mental status (AMS)
Chief complaint – stimulant term No, must use in combination with overdose term Speedball, Cocaine, Coke, Crack, Amphetamine (will catch methamphetamine), meth, Crystal meth, Lisdexamfetamine, Dextroamphetamine, Levoamphetamine, Biphetamine, Dexedrine, Adderal, Vyvanse, Concerta, Methylin, Ritalin, Cathinone, Bath salt, Stimulant, MDMA, Ecstasy, Molly
Exclusions
Chief complaint Exclude Requests for drugs/drug-seeking behaviors
Detoxification
Withdrawal
Denying drug use
Denying loss of consciousness or shortness of breath, etc.
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