Overdose Deaths Involving Opioids, Cocaine, and Psychostimulants — United States, 2015–2016

Puja Seth, PhD; Lawrence Scholl, PhD; Rose A. Rudd, MSPH; Sarah Bacon, PhD

Disclosures

Morbidity and Mortality Weekly Report. 2018;67(12):349-358. 

In This Article

Abstract and Introduction

Introduction

During 1999–2015, 568,699 persons died from drug overdoses in the United States.* Drug overdose deaths in the United States increased 11.4% from 2014 to 2015 resulting in 52,404 deaths in 2015, including 33,091 (63.1%) that involved an opioid. The largest rate increases from 2014 to 2015 occurred among deaths involving synthetic opioids other than methadone (synthetic opioids) (72.2%).[1] Because of demographic and geographic variations in overdose deaths involving different drugs,[2,3] CDC examined age-adjusted death rates for overdoses involving all opioids, opioid subcategories (i.e., prescription opioids, heroin, and synthetic opioids),§ cocaine, and psychostimulants with abuse potential (psychostimulants) by demographics, urbanization levels, and in 31 states and the District of Columbia (DC). There were 63,632 drug overdose deaths in 2016; 42,249 (66.4%) involved an opioid. From 2015 to 2016, deaths increased across all drug categories examined. The largest overall rate increases occurred among deaths involving cocaine (52.4%) and synthetic opioids (100%), likely driven by illicitly manufactured fentanyl (IMF).[2,3] Increases were observed across demographics, urbanization levels, and states and DC. The opioid overdose epidemic in the United States continues to worsen. A multifaceted approach, with faster and more comprehensive surveillance, is needed to track emerging threats to prevent and respond to the overdose epidemic through naloxone availability, safe prescribing practices, harm-reduction services, linkage into treatment, and more collaboration between public health and public safety agencies.

Drug overdose deaths were identified in the National Vital Statistics System multiple cause-of-death mortality files,** using the International Classification of Diseases, Tenth Revision (ICD-10), based on ICD-10 underlying cause-of-death codes X40–44 (unintentional), X60–64 (suicide), X85 (homicide), or Y10–Y14 (undetermined intent). Among deaths with drug overdose as the underlying cause, the type of drug or drug category 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/semisynthetic opioids (T40.2); methadone (T40.3); heroin (T40.1); synthetic opioids other than methadone (T40.4); cocaine (T40.5); and psychostimulants with abuse potential (T43.6). Some deaths involved more than one type of drug; these deaths were included in the rates for each drug category. Therefore, categories are not mutually exclusive.§§

Age-adjusted overdose death rates¶¶ were examined for 2015 and 2016 for all opioids, opioid subcategories (prescription opioids [i.e., natural/semisynthetic opioids and methadone],[4] heroin, and synthetic opioids), cocaine, and psychostimulants in the United States and by age, sex, racial/ethnic group, urbanization level,*** and state. State-level analyses included 31 states and DC that met the following criteria: 1) ≥80% of drug overdose death certificates named at least one specific drug in 2015 and 2016; 2) change from 2015 to 2016 in the percentage of death certificates reporting at least one specific drug was <10 percentage points†††; and 3) ≥20 deaths occurred during 2015 and 2016 in at least two drug categories examined. These inclusion criteria were selected to ensure accurate examination of death rates and increases. Relative change in age-adjusted rates and absolute change were calculated. Significance was assessed using z-tests when the number of deaths was ≥100 (p<0.05) and nonoverlapping confidence intervals based on a gamma distribution when the number of deaths was <100.§§§

In the United States, 63,632 drug overdose deaths occurred in 2016; the age-adjusted rate of overdose deaths increased significantly (21.5%) from 16.3 in 2015 to 19.8 in 2016. Opioids were involved in 42,249 (66.4%) drug overdose deaths (13.3 per 100,000 population) in 2016, representing a 27.9% rate increase from 2015 (Table 1). These increases primarily were driven by deaths involving synthetic opioids, for which the rate doubled from 2015 to 2016 (Table 2). Rates of overdose deaths involving prescription opioids and heroin increased by 10.6% and 19.5%, respectively (Table 1) (Table 2), and rates of overdose deaths involving cocaine and psychostimulants increased by 52.4% and 33.3%, respectively (Table 3).

From 2015 to 2016, opioid-involved deaths increased in males and females and among persons aged ≥15 years, whites, blacks, Hispanics, and Asian/Pacific Islanders. The largest relative rate change occurred among blacks (56.1%) (Table 1). The largest absolute rate increases of opioid-involved deaths and deaths involving synthetic opioids occurred among males aged 25–44 years and persons aged 25–34 years. However, deaths involving synthetic opioids increased in every subgroup examined (Table 2). Rates involving prescription opioids, heroin, cocaine, and psychostimulants increased for both sexes, whites, blacks, and most age groups (Table 1) (Table 2) (Table 3). Counties in large central and fringe metro areas experienced the largest absolute increases in deaths involving prescription and synthetic opioids, heroin, and cocaine; micropolitan areas experienced the largest increase in rates involving psychostimulants (Table 1) (Table 2) (Table 3).

Opioid death rates differed across the 31 states and DC, with synthetic opioids driving increases in many states.¶¶¶ Although several states experienced increases across drug categories, in many, the changes from 2015 to 2016 were not significant. Rates of deaths involving synthetic opioids ranged from 0.9 to 30.3 per 100,000, with the largest rates and increases concentrated in eastern states. New Hampshire (30.3 per 100,000), West Virginia (26.3), and Massachusetts (23.5) had the highest synthetic opioid death rates. Twenty states and DC experienced increases in overdose death rates involving synthetic opioids, with 10 experiencing increases by ≥100%; the largest such increase (392.3%) occurred in DC, followed by Illinois (227.3%) and Maryland (206.9%) (Table 2). Many states with large increases in synthetic opioid death rates also had large increases in rates involving other drug categories (e.g., Maryland, Virginia, and DC), including any opioid, prescription opioids (Table 1), heroin (Table 2), and cocaine (Table 3).

Thirteen states and DC experienced significant increases in heroin-involved death rates, whereas a significant decrease (56.9%) occurred in New Hampshire (Table 2). In 2016, the highest rates were in DC (17.3 per 100,000), West Virginia (14.9), and Ohio (13.5). The rates of prescription opioid–involved overdose deaths significantly increased in seven states and DC, with the highest rates in West Virginia (19.7), Maryland (13.1), Maine (12.5), and Utah (12.5) (Table 1). The highest cocaine-involved overdose death rates occurred in DC (13.5), Rhode Island (10.7), and Ohio (10.1), with 15 states and DC experiencing a significant increase from 2015 (Table 3). Significant increases in overdose death rates from heroin, prescription opioids, and cocaine occurred primarily in states in the eastern part of the country. Fourteen states experienced significant increases in psychostimulant-involved overdose death rates. The highest rates were in midwestern and western states: Nevada (7.5), New Mexico (7.1), and Oklahoma (7.1) (Table 3).

*https://wonder.cdc.gov.
https://www.cdc.gov/drugoverdose/pdf/pubs/2017-cdc-drug-surveillance-report.pdf.
§Natural opioids include morphine and codeine, and semisynthetic opioids include drugs such as oxycodone, hydrocodone, hydromorphone, and oxymorphone. Methadone is a synthetic opioid. Synthetic opioids, other than methadone, include drugs such as tramadol and fentanyl. Heroin is an illicit opioid synthesized from morphine that can be a white or brown powder, or a black sticky substance.
https://www.cdc.gov/nchs/products/databriefs/db294.htm.
**https://www.cdc.gov/nchs/nvss/mortality_public_use_data.htm.
††T40.0 (opium) and T40.6 (other and unspecified narcotics).
§§For example, a death involving both a synthetic opioid other than methadone and heroin would be included in both the synthetic other than methadone and heroin death rates.
¶¶Age-adjusted death rates were calculated by applying age-specific death rates to the 2000 U.S. Census standard population age distribution. https://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_04.pdf.
***Categories of 2013 NCHS Urban-Rural Classification Scheme for Counties (https://www.cdc.gov/nchs/data_access/urban_rural.htm): Large central metro: Counties in metropolitan statistical areas (MSAs) of ≥1 million population that 1) contain the entire population of largest principal city of the MSA, or 2) have their entire population contained in the largest principal city of the MSA, or 3) contain at least 250,000 inhabitants of any principal city of the MSA; Large fringe metro: Counties in MSAs of ≥1 million population that did not qualify as large central metro counties; Medium metro: Counties in MSAs of populations of 250,000–999,999; Small metro: Counties in MSAs of populations <250,000; Micropolitan (nonmetropolitan counties): counties in micropolitan statistical areas; Noncore (nonmetropolitan counties): nonmetropolitan counties that did not qualify as micropolitan.
†††States whose reporting of any specific drug or drugs involved in an overdose changed by ≥10 percentage points from 2015 to 2016 were excluded because drug-specific overdose numbers and rates might have changed substantially from 2015 to 2016 as a result of changes in reporting.
§§§Z-tests were used if the number of deaths was ≥100, and a p-value of <0.05 was considered to be statistically significant. Nonoverlapping confidence intervals based on the gamma method were used if the number of deaths was <100 in 2015 or 2016. Note that the method of comparing confidence intervals is a conservative method for statistical significance; caution should be observed when interpreting a nonsignificant difference when the lower and upper limits being compared overlap only slightly.
¶¶¶Maps and figures providing significant changes in drug overdose and opioid-involved overdose death rates by state are available on CDC's Drug Overdose website: https://www.cdc.gov/drugoverdose/data.

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