Opportunities to Prevent Overdose Deaths Involving Prescription and Illicit Opioids, 11 States, July 2016–June 2017

Christine L. Mattson, PhD; Julie O'Donnell, PhD; Mbabazi Kariisa, PhD; Puja Seth, PhD; Lawrence Scholl, PhD; R. Matthew Gladden, PhD

Disclosures

Morbidity and Mortality Weekly Report. 2018;67(34):945-951. 

In This Article

Abstract and Introduction

Introduction

In 2016, 63,632 drug overdose deaths occurred in the United States, 42,249 (66.4%) of which involved opioids.[1] The development of prevention programs are hampered by a lack of timely data on specific substances contributing to and circumstances associated with fatal overdoses. This report describes opioid overdose deaths (referred to as opioid deaths) for decedents testing positive for prescription opioids (e.g., oxycodone and hydrocodone), illicit opioids (e.g., heroin, illicitly manufactured fentanyl, and fentanyl analogs), or both prescription and illicit opioids, and describes circumstances surrounding the overdoses, in 11 states participating in CDC's Enhanced State Opioid Overdose Surveillance (ESOOS) program.* During July 2016–June 2017, among 11,884 opioid overdose deaths, 17.4% of decedents tested positive for prescription opioids only, 58.7% for illicit opioids only, and 18.5% for both prescription and illicit opioids (type of opioid could not be classified in 649 [5.5%] deaths). Approximately one in 10 decedents had been released from an institutional setting in the month preceding the fatal overdose. Bystanders were reportedly present in approximately 40% of deaths; however, naloxone was rarely administered by a layperson. Enhanced surveillance data from 11 states provided more complete information on the substances involved in and circumstances surrounding opioid overdose deaths. Consistent with other emerging evidence and recommendations, these data suggest prevention efforts should prioritize naloxone distribution to persons misusing opioids or using high dosage prescription opioids and to their family members and friends. In addition, these data suggest a need to expand treatment and support for persons who have experienced a nonfatal overdose and to expand treatment in detention facilities and upon release.

CDC funds 32 states and the District of Columbia to abstract death certificate and medical examiner and coroner data, including toxicology results, on opioid deaths, through the State Unintentional Drug Overdose Reporting System, a component of ESOOS. Data are collected on death scene investigations (e.g., evidence of illicit or prescription drug use), circumstances occurring close in time to the death (e.g., presence of bystanders), history of substance use treatment, prior history of overdose, and demographics. For all opioid deaths classified as unintentional or of undetermined intent, states list all positive tests for opioid and nonopioid substances ("present" or "detected"), and whether the medical examiner or coroner determined that the substance contributed to the overdose death ("involved").§ CDC analyzed demographics, routes of administration, co-use of other substances, and overdose circumstances by involvement of prescription opioids only, illicit opioids only,** or the presence of both prescription and illicit opioids,†† for deaths that occurred during July 2016–June 2017 in 11 ESOOS states.§§

Among 11,884 opioid deaths, 2,066 (17.4%) involved prescription opioids only, 6,975 (58.7%) involved illicit opioids only, and for 2,194 (18.5%) both prescription and illicit opioids were detected; type of opioid could not be classified in 649 (5.5%) deaths, leaving 11,235 deaths for analysis. Among deaths for which both prescription and illicit opioids were detected, medical examiners or coroners determined that both prescription and illicit opioids contributed to 59.2% of deaths, illicit opioids alone contributed to 39.8% of deaths, and prescription opioids alone contributed to 1.0% of deaths. The percentage of deaths involving different opioid types varied across states (Figure), with the highest percentages of prescription opioid–only deaths in the West (Oklahoma: 72.2%; New Mexico: 35.0%), and the highest percentages of illicit opioid–only deaths, ranging from 47.6% to 72.1%, in the Northeast (Maine, Massachusetts, New Hampshire, and Rhode Island) and the Midwest (Missouri, Ohio, West Virginia, and Wisconsin). Kentucky had the highest percentage of deaths with both prescription and illicit opioids (26.5%) present, followed by Missouri (25.1%).

Figure.

Percentage of opioid overdose deaths in which prescription opioids only,* illicit opioids only, or both prescription and illicit opioids§ were detected, by state — 11 states, July 1, 2016–June 30, 2017
*Oxycodone, oxymorphone, hydrocodone, hydromorphone, tramadol, buprenorphine, methadone, meperidine, tapentadol, dextrorphan, levorphanol, propoxyphene, noscapine, pentazocine, and phenacetin. Brand names (e.g., Opana), metabolites (e.g., nortramadol) of these substances, and these substances in combination with nonopioids (e.g., acetaminophen-oxycodone) were included as prescription opioids. Morphine and codeine were coded as prescription opioids if scene or other evidence indicated their presence as a result of consumption of prescription morphine or codeine, rather than as a result of metabolism of or impurities of heroin, respectively. Fentanyl was coded as a prescription opioid if scene or other evidence indicated likely consumption of prescription fentanyl rather than illicitly manufactured fentanyl. Decedents might have tested positive for other nonopioid substances. This analysis does not distinguish whether prescription drugs were prescribed to the decedent or diverted.
Heroin, fentanyl analogs, and U-47700. Fentanyl was coded as illicit if scene or other evidence indicated that it was more likely illicitly manufactured than pharmaceutical. Decedents might have tested positive for other nonopioid substances.
§Deaths were coded as positive for both prescription and illicit opioids if one or more opioids from both categories were detected on postmortem toxicology testing. Decedents might have tested positive for other nonopioid substances.

Among prescription opioid–only deaths, the median age of decedents was 47 years, 51.0% were female, and 86.2% were non-Hispanic white (white). Among illicit opioid–only deaths, the median age of decedents was 36 years, 73.0% were male, and 81.1% were white. Among deaths for which both prescription and illicit opioids were detected, decedents' median age was 39 years, 70.5% were male, and 83.6% were white (Table).

Evidence of injection drug use was found in approximately half of illicit opioid deaths, but only 6.6% of prescription opioid–only deaths. Other drugs were frequently detected in opioid deaths (Table). Benzodiazepines and gabapentin were detected in 51.6% and 21.6% of prescription opioid–only deaths, respectively. Among illicit opioid–only deaths, cocaine was detected in 34.9% of deaths and benzodiazepines were detected in 24.0% of deaths. Among deaths for which both prescription and illicit opioids were detected, benzodiazepines were detected in 44.5% and cocaine in 34.8%.

Approximately one in 10 decedents had evidence of having been released from an institutional setting in the month preceding the fatal overdose, with the most common settings being jail, prison, or detention facilities when only illicit opioids were involved (4.9%), and hospitals when only prescription opioids were involved (4.1%). Previous drug overdose at any time before the fatal overdose was noted in 15.1% of illicit opioid–only deaths, 13.5% of deaths with both prescription and illicit opioids present, and 9.3% of prescription opioid–only deaths. Bystanders were reported to have been present in 44% of opioid deaths, but naloxone was seldom administered by a layperson (in approximately 4% of deaths involving only illicit opioids and 0.8% of prescription opioid–only deaths).

*CDC's Enhanced State Opioid Overdose Surveillance program funded 12 states through a competitive application process in fiscal year 2016, and an additional 20 states and the District of Columbia in fiscal year 2017. Data were available for Kentucky, Maine, Massachusetts, Missouri, New Hampshire, New Mexico, Ohio, Oklahoma, Rhode Island, West Virginia, and Wisconsin for this report. https://www.cdc.gov/drugoverdose/foa/state-opioid-mm.html.
https://www.surgeongeneral.gov/priorities/opioid-overdose-prevention/naloxone-advisory.html.
§State Unintentional Drug Overdose Reporting System (SUDORS) estimates of opioid-involved overdose deaths might differ from those of the National Vital Statistics System because SUDORS uses preliminary death certificate data and collects additional information from medical examiner and coroner reports, which are abstracted within 8 months of death. In SUDORS, an opioid-involved overdose death either was identified through review of the medical examiner/coroner report or had International Classification of Diseases, Tenth Revision (ICD-10) underlying cause-of-death codes X40–44 (unintentional) or Y10–Y14 (undetermined) and multiple cause-of-death codes of T40.0, T40.1, T40.2, T40.3, T40.4, or T40.6 on the death certificate. Data for this report were downloaded on June 30, 2018, and might differ from reports using earlier data.
Substances coded as prescription opioids were oxycodone, oxymorphone, hydrocodone, hydromorphone, tramadol, buprenorphine, methadone, meperidine, tapentadol, dextrorphan, levorphanol, propoxyphene, noscapine, pentazocine, and phenacetin. Brand names (e.g., Opana), metabolites (e.g., nortramadol) of these substances, and these substances in combination with nonopioids (e.g., acetaminophen-oxycodone) were included as prescription opioids as well. Morphine and codeine were coded as prescription opioids if scene or other evidence indicated their presence as a result of consumption of prescription morphine or codeine, rather than as a result of metabolism of or impurities of heroin, respectively. Fentanyl was coded as a prescription opioid if scene or other evidence indicated likely consumption of prescription fentanyl rather than illicitly manufactured fentanyl. Decedents might have tested positive for other nonopioid substances. This analysis does not distinguish between prescription drugs prescribed to the decedent and those that were diverted.
**Substances coded as illicit opioids were heroin, fentanyl analogs, and U-47700. Fentanyl was coded as illicit if scene or other evidence indicated that it was more likely to have been illicitly manufactured than pharmaceutical. Decedents might have tested positive for other nonopioid substances.
††Deaths were coded as positive for both prescription and illicit opioids if one or more opioids from both categories were detected on postmortem toxicology testing. Decedents might have tested positive for other nonopioid substances.
§§Twelve states were funded through a competitive application process in September 2016 (Kentucky, Maine, Massachusetts, Missouri, New Hampshire, New Mexico, Ohio, Oklahoma, Pennsylvania, Rhode Island, West Virginia, and Wisconsin). An additional 20 states (Alaska, California, Connecticut, Delaware, Florida, Georgia, Illinois, Indiana, Louisiana, Maryland, Michigan, Minnesota, Nevada, New Jersey, North Carolina, Tennessee, Utah, Vermont, Virginia, and Washington) and the District of Columbia were funded in September 2017. Data were available for 11 of the 33 jurisdictions for this report.

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