A new study published in the Journal of Urban Health could have a significant impact on the way heroin overdose cases are counted and may dramatically increase the number of reported heroin-related deaths across the country.
Researchers at the IU School of Public and Environmental Affairs at Indiana University-Purdue University analyzed accidental opioid overdoses in Marion County, Indiana, from 2010 through 2015 and discovered that deaths where heroin was present may be significantly undercounted.
During the six-year study period, the IUPUI team examined the death certificates and toxicology reports for 1,199 accidental drug-overdose fatalities in Marion County and classified 455 as heroin-related.
During the same time period, the Marion County Public Health Department recorded just 141 deaths caused by heroin.
“What happens a lot of times when people overdose is that they have multiple substances in their system,” said Brad Ray, an assistant professor in the School of Public and Environmental Affairs who studies substance abuse.
“Because of the use of poly-drug codes to classify deaths when multiple drugs are present, we tend to undercount the prevalence of heroin in deaths because we usually count whether the death was a result of heroin rather than whether heroin was present.”
While guidelines from laboratory toxicologists suggest that 6-monoacetylmorphine is the definitive text for illicit heroin, the IUPUI researchers coded cases that had both morphine and codeine — but not 6-monoacetylmorphine — as heroin cases [because] …heroin undergoes a rapid metabolic transformation into those natural opioids, so heroin-related toxicology reports sometimes show signs of morphine and codeine but not 6-monoacetylmorphine.
So heroin overdoses were misclassified as prescription opioid deaths. This almost seems a deliberate effort to besmirch the reputation of prescription opioids
“Anytime you would see those two substances together, the research suggests that it has to be heroin,” Ray said. “Being able to work with the Marion County Coroner’s Office and comb through the toxicology reports allowed us to see how often heroin was present in drug-overdose deaths and not just the primary cause of death.”
The number of heroin-related deaths increased more than 400 percent over the six-year time frame, from 22 in 2010 to 111 in 2015.
The overdose rate for fentanyl also increased dramatically during the study period, from 15 to 63, or 320 percent.
Total opioid-related overdoses doubled, from 129 to 260.
While deaths from heroin and fentanyl saw sizable increases, overdoses from prescription opiates declined or remained relatively flat.
What we’ve all known intuitively would happen is becoming visible to the public, or at least, researchers: our prescription opioids play no part in the overdose crisis.
The researchers were also able to gather Marion County data on prescription-drug patterns from Indiana Scheduled Prescription Electronic Collection and Tracking.
They discovered that following large decreases in prescriptions for opioids in 2013 and 2014, there were marked increases in heroin- and fentanyl-related deaths in 2014 and 2015.
after reaching a high of 1.8 million prescriptions in 2012, hydrocodone prescriptions fell by 30 percent during the last three years of the research period.
While hydrocodone accounted for 38 percent of all opioid drug overdoses in 2010, that figure fell to just 17 percent, or 35 deaths, in 2015.
“One of the big hypotheses right now is that people have moved from prescription medication to heroin, and our research would suggest that it’s true,”
It sounds like they’re beginning to “get it”. Finally.
Senate Bill 74 would require coroners who are investigating overdose deaths to perform a “drugs of abuse” panel to detect the presence of Schedule I and Schedule II controlled substances. The results of those deaths would then be forwarded to the Indiana Department of Health.
“This is an incredibly important issue, because we don’t know how many people are actually dying with heroin in their system,” Ray said. “And fentanyl is the drug that has everyone nervous right now. I would bet when we get the 2016 numbers, we’ll be looking at an equal number of deaths between fentanyl and heroin.”
You can download a full copy of the report.