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. |
