CDC: Drug and Opioid Overdose Deaths 2014

Increases in Drug and Opioid Overdose Deaths — United States, 2000–2014 – December 18, 2015 / 64(Early Release);1-5

This government document seems to contains a suspicious kind of counting:

Some deaths involve more than one type of opioid; these deaths were included in the rates for each category.

To me, that sentence above makes the statistical analyses suspect by counting some overdoses multiple times. I don’t trust that this count has been limited just to the categorizations.  If a person dies with heroin, methadone, and oxycodone in their system, that could count as three overdoses.

(e.g., a death involving both a synthetic opioid and heroin would be included in the rates for synthetic opioid deaths and in the rates for heroin deaths).

This could inflate the numbers of overdoses from opioids. 

The CDC document begins like this:

The United States is experiencing an epidemic of drug overdose (poisoning) deaths. Since 2000, the rate of deaths from drug overdoses has increased 137%, including a 200% increase in the rate of overdose deaths involving opioids (opioid pain relievers and heroin).

CDC analyzed recent multiple cause-of-death mortality data to examine current trends and characteristics of drug overdose deaths, including the types of opioids associated with drug overdose deaths.

Later, they admit they can’t tell the difference between some types of opioids.

During 2014, a total of 47,055 drug overdose deaths occurred in the United States, representing a 1-year increase of 6.5%, from 13.8 per 100,000 persons in 2013 to 14.7 per 100,000 persons in 2014.

The rate of drug overdose deaths increased significantly for both sexes, persons aged 25–44 years and ≥55 years, non-Hispanic whites and non-Hispanic blacks, and in the Northeastern, Midwestern, and Southern regions of the United States.

Rates of opioid overdose deaths also increased significantly, from 7.9 per 100,000 in 2013 to 9.0 per 100,000 in 2014, a 14% increase.

Historically, CDC has programmatically characterized all opioid pain reliever deaths (natural and semisynthetic opioids, methadone, and other synthetic opioids) as “prescription” opioid overdoses (1).

Between 2013 and 2014, the age-adjusted rate of death involving methadone remained unchanged; however, the age-adjusted rate of death involving natural and semisynthetic opioid pain relievers, heroin, and synthetic opioids, other than methadone (e.g., fentanyl) increased 9%, 26%, and 80%, respectively.

The sharp increase in deaths involving synthetic opioids, other than methadone, in 2014 coincided with law enforcement reports of increased availability of illicitly manufactured fentanyl, a synthetic opioid; however, illicitly manufactured fentanyl cannot be distinguished from prescription fentanyl in death certificate data.

If fentanyl can be manufactured, I expect it will quickly grow in popularity. The fentanyl “high” is much cheaper than that from either prescription drugs (the most expensive) or heroin.

Fentanyl is also so powerful that it will be easy to overdose. Just a small increase in dosage could have deadly effects, so I expect there will be a rise in fentanyl overdoses. Other opioid overdoses would then decline as more abusers switch to the cheaper “high”.

Just like it happened with amphetamines, the DEA is going to find it almost impossible to control the supply of this opioid.

These findings indicate that the opioid overdose epidemic is worsening. There is a need for continued action to prevent opioid abuse, dependence, and death, improve treatment capacity for opioid use disorders, and reduce the supply of illicit opioids, particularly heroin and illicit fentanyl.

The National Vital Statistics System multiple cause-of-death mortality files were used to identify drug overdose deaths.*

I wonder how many of these were intentional suicides…

Drug overdose deaths were classified using the International Classification of Disease, Tenth Revision (ICD-10), based on the ICD-10 underlying cause-of-death codes

  • X40–44 (unintentional)
  • X60–64 (suicide)
  • X85 (homicide), or
  • Y10–Y14 (undetermined intent) (2).

Among the deaths with drug overdose as the underlying cause, the type of opioid involved is indicated by the following ICD-10 multiple cause-of-death codes:

  • opioids (T40.0, T40.1, T40.2, T40.3, T40.4, or T40.6);
  • natural and semisynthetic opioids (T40.2);
  • methadone (T40.3);
  • synthetic opioids, other than methadone (T40.4);
  • heroin (T40.1).

Then, they give various statistical conclusions they reached from this un-verified data.

  • During 2014, 47,055 drug overdose deaths occurred in the United States. Since 2000, the age-adjusted drug overdose death rate has more than doubled, from 6.2 per 100,000 persons in 2000 to 14.7 per 100,000 in 2014 (Figure 1).
  • The overall number and rate of drug overdose deaths increased significantly from 2013 to 2014, with an additional 3,073 deaths occurring in 2014 (Table), resulting in a 6.5% increase in the age-adjusted rate.
  • From 2013 to 2014, statistically significant increases in drug overdose death rates were seen for both males and females, persons aged 25–34 years, 35–44 years, 55–64 years, and ≥65 years; non-Hispanic whites and non-Hispanic blacks; and residents in the Northeast, Midwest and South Census Regions (Table).
  • In 2014, the five states with the highest rates of drug overdose deaths were West Virginia (35.5 deaths per 100,000), New Mexico (27.3), New Hampshire (26.2), Kentucky (24.7) and Ohio (24.6).†
  • States with statistically significant increases in the rate of drug overdose deaths from 2013 to 2014 included Alabama, Georgia, Illinois, Indiana, Maine, Maryland, Massachusetts, Michigan, New Hampshire, New Mexico, North Dakota, Ohio, Pennsylvania, and Virginia.

I’m furious that they talk so much about the damning numbers when their statistical methods are so terribly suspect.

Here, the article includes more statistics and graphs.

Discussion

More persons died from drug overdoses in the United States in 2014 than during any previous year on record. 

They haven’t accounted for the increasing population. Simply counting the numbers each year is not meaningful.

They have carefully chosen comparisons that make the opioid overdoses seem outrageously large, but using different comparisons (as I’ve shown below) show the magnitude is much less than other, easier to address, problems:

“From 2000 to 2014 nearly half a million persons in the United States have died from drug overdoses.”

On the other hand…

From 2000 to 2014, nearly two million persons in the United States have died from preventable hospital errors. (440,000/year, over 1,000 lives every day)

And:

“In 2014, there were approximately one and a half times more drug overdose deaths in the United States than deaths from motor vehicle crashes (4).”

On the other hand…

In 2014, there were only one-half as many drug overdose deaths in the United States than deaths from suicide.

The same sentences, using different comparisons, show how outrageous it is to call the overdoses a “crisis” or “epidemic”.

The “opioid crisis” seems to be a case of misplaced (or manufactured) priorities.

Opioids, primarily prescription pain relievers and heroin, are the main drugs associated with overdose deaths.

In 2014, opioids were involved in 28,647 deaths, or 61% of all drug overdose deaths; the rate of opioid overdoses has tripled since 2000.

Here the article arranges the statistics in various combinations, designed to bolster the case against opioids.

The rate of drug overdose deaths involving synthetic opioids nearly doubled between 2013 and 2014. This category includes both prescription synthetic opioids (e.g., fentanyl and tramadol) and non-pharmaceutical fentanyl manufactured in illegal laboratories (illicit fentanyl).

Toxicology tests used by coroners and medical examiners are unable to distinguish between prescription and illicit fentanyl.

So they categorize it, even though they can’t tell which it is. Could this have been solved by adding them to both “Rx fentanyl” and “illicit fentanyl” overdoses, as they do when there are multiple opioids present? This is another counting “trick” that would increase the number of overdoses.

Based on reports from states and drug seizure data, however, a substantial portion of the increase in synthetic opioid deaths appears to be related to increased availability of illicit fentanyl (7), although this cannot be confirmed with mortality data.

For example, five jurisdictions (Florida, Maryland, Maine, Ohio, and Philadelphia, Pennsylvania) that reported sharp increases in illicit fentanyl seizures, and screened persons who died from a suspected drug overdose for fentanyl, detected similarly sharp increases in fentanyl-related deaths (7).§

Finally, illicit fentanyl is often combined with heroin or sold as heroin. Illicit fentanyl might be contributing to recent increases in drug overdose deaths involving heroin. Therefore, increases in illicit fentanyl-associated deaths might represent an emerging and troubling feature of the rise in illicit opioid overdoses that has been driven by heroin.

The findings in this report are subject to at least three limitations.

First, several factors related to death investigation might affect estimates of death rates involving specific drugs. At autopsy, toxicological laboratory tests might be performed to determine the type of drugs present; however, the substances tested for and circumstances under which the tests are performed vary by jurisdiction.

Second, in 2013 and 2014, 22% and 19% of drug overdose deaths, respectively, did not include information on the death certificate about the specific types of drugs involved. The percent of overdose deaths with specific drugs identified on the death certificate varies widely by state. Some of these deaths might have involved opioids. This increase in the reporting of specific drugs in 2014 might have contributed to some of the observed increases in drug overdose death rates involving different types of opioids from 2013 to 2014.

Finally,some heroin deaths might be misclassified as morphine because morphine and heroin are metabolized similarly (8), which might result in an underreporting of heroin overdose deaths.

This, in addition to not being able to tell the difference between two types/sources of fentanyl. But it doesn’t stop them from classifying it anyway and publicizing these uncorrected figures.

To reverse the epidemic of opioid drug overdose deaths and prevent opioid-related morbidity, efforts to improve safer prescribing of prescription opioids must be intensified. CDC has developed a draft guideline for the prescribing of opioids for chronic pain to address this need.

In addition, efforts are needed to protect persons already dependent on opioids from overdose and other harms.

This includes expanding access to and use of naloxone (a safe and effective antidote for all opioid-related overdoses)** and increasing access to medication-assisted treatment, in combination with behavioral therapies (9).

Efforts to ensure access to integrated prevention services, including access to syringe service programs when available, is also an important consideration to prevent the spread of hepatitis C virus and human immunodeficiency virus infections from injection drug use.

Both pain patients and addicts need access to the medications and treatments that are effective for them as individuals.

The choices should not be limited by politics or morality, but rather reflect the knowledge and experience of professionals, those working in tandem with their patients, willing to try a wide variety of treatments alone or in combinations.

Completely ineffecient, and thus shunned by insurance companies, the trial and error method is the only way to discover what treatments are effective for individual patients.  A doctor’s expertise will always be needed to understand which methods are the most likely to be effective.

Collaboration and trust between doctors and their patients is absolutely necessary to assure the full and honest feedback needed for trail and error. This can only happen if the patient can trust that doctor is motivated by the patient’s welfare, helping them find a way to be as functional as possible.

Public health agencies, medical examiners and coroners, and law enforcement agencies can work collaboratively to improve detection of outbreaks of drug overdose deaths involving illicit opioids (including heroin and illicit fentanyl) through improved investigation and testing as well as reporting and monitoring of specific drugs, and facilitate a rapid and effective response that can address this emerging threat to public health and safety (7). Efforts are needed to distinguish the drugs contributing to overdoses to better understand this trend.

Oddly, this report was published by the “Division of Unintentional Injury Prevention”, National Center for Injury Prevention and Control, CDC.

 

References

  1. Paulozzi LJ, Jones C, Mack K, Rudd R. Vital signs: overdoses of prescription opioid pain relievers—United States, 1999–2008. MMWR Morb Mortal Wkly Rep 2011;60:1487–92.
  2. Bergen G, Chen LH, Warner M, Fingerhut LA. Injury in the United States: 2007 chartbook. Hyattsville, MD: National Center for Health Statistics; 2008 Available at http://www.cdc.gov/nchs/data/misc/injury2007.pdf Adobe PDF file.
  3. Murphy SL, Xu JQ, Kochanek KD. Deaths: final data for 2010. National vital statistics reports. Hyattsville, MD: National Center for Health Statistics; 2013. Available at http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_04.pdf Adobe PDF file.
  4. CDC. Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2015. Available at http://wonder.cdc.gov.
  5. Jones CM, Logan J, Gladden RM, Bohm MK. Vital signs: demographic and substance use trends among heroin users—United States, 2002–2013. MMWR Morb Mortal Wkly Rep 2015;64:719–25.
  6. Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. The changing face of heroin use in the United States: a retrospective analysis of the past fifty years. JAMA Psychiatry 2014;71:821–6.
  7. CDC. Increases in fentanyl drug confiscations and fentanyl-related overdose fatalities. HAN Health Advisory. Atlanta, GA: US Department of Health and Human Services, CDC; 2015. Available at http://emergency.cdc.gov/han/han00384.asp.
  8. Davis GG. Complete republication: National Association of Medical Examiners position paper: recommendations for the investigation, diagnosis, and certification of deaths related to opioid drugs. J Med Toxicol 2014;10:100–6.
  9. Volkow ND, Frieden TR, Hyde PS, Cha SS. Medication-assisted therapies—tackling the opioid-overdose epidemic. N Engl J Med 2014;370:2063–6.

Additional information available at:

This is followed by many excellent graphs of the (uncorrected, i.e. invalid) data.

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2 thoughts on “CDC: Drug and Opioid Overdose Deaths 2014

  1. Pingback: CDC may have over-counted opioid overdoses | EDS Info (Ehlers-Danlos Syndrome)

  2. Pingback: What Alternatives do Pain Patients Have? | EDS Info (Ehlers-Danlos Syndrome)

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