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 |
|---|---|---|
| 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 |
| 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 |
|---|---|---|
| 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 |
| 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. |
The following four data reports come from CDC’s ESOOSpdf icon program, which was funded from 2016-2019 to provide more timely and comprehensive data on fatal and nonfatal opioid overdoses and risk factors associated with fatal overdoses. Twelve states were initially funded in September 2016, and an additional 20 states and the District of Columbia were funded in September 2017, to share data on nonfatal all drug, all opioid, and/or heroin overdoses with CDC on a quarterly basis. Data from ESOOS have not been updated since April 2019, and data may differ from those in the DOSE system. For example, ESOOS states were able to develop and apply their own overdose case definitions, whereas DOSE required standardized case definitions to be used across all funded recipients. Furthermore, stimulant overdose data are reported in the DOSE System but were not collected during ESOOS.
Data Reports from CDC’s DOSE system on overdoses during the COVID-19 pandemic
The data report below comes from CDC’s DOSE system. The report displays total ED visits, ED visit counts for suspected overdoses, and overdose rates overall and by 42 states, including the District of Columbia, through September 2020. During the first several months of the COVID-19 pandemic, the number of total ED visits across the United States substantially declined; however, nonfatal overdoses did not decline at a similar pace.
There are several important caveats to consider when viewing the figures included in this report. During the COVID-19 pandemic, states onboarded new facilities that began sharing data; also, some facilities stopped sharing data during this period. Thus, the number of facilities was not constant over this time period. In addition, states collaborated with existing facilities to increase the proportion of ED visits that contained diagnosis codes, which facilitates the identification of overdose-related visits. Caution is warranted in interpreting counts, rates, and comparisons to previous years due to these data issues.
