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


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

In This Article


This report is one of the first to use medical examiner and coroner reports across multiple states and provides information that can be used to better inform prevention and response programs related to opioid overdose deaths. Specifically, among these 11 states, there is improved understanding of prescription and illicit opioid involvement, polysubstance use, and potential missed opportunities to intervene to prevent opioid overdose deaths. Previous efforts to differentiate illicit and prescription opioid deaths were limited by grouping within the same drug categories (e.g., synthetic opioids, excluding methadone) and by the difficulty in determining whether detection of morphine or fentanyl by forensic toxicology testing indicates the presence of prescription or illicit opioids.[2,3] ¶¶ Findings from this analysis indicate that illicit opioids were a major driver of opioid deaths, especially among younger persons, and were detected in approximately three of four deaths overall. Prescription opioids were detected in approximately four of 10 deaths. Illicit opioids predominated in all states except Oklahoma.

Among these 11 states, the evolving opioid overdose epidemic differentially affects states and regions, but most states were simultaneously struggling with a complex mix of prescription and illicit opioid deaths. In this analysis, four polysubstance use patterns highlight an urgent need for targeted and comprehensive action. First, approximately half of prescription opioid–only deaths tested positive for benzodiazepines, which are known to depress the central nervous system and increase the risk of overdose and death.*** This high-risk drug-use pattern can be targeted for intervention. Second, gabapentin (a nonopioid medication commonly prescribed for neuropathic pain), was found in approximately one in five prescription opioid–only deaths and in approximately one in 10 deaths in the other groups. Consistent with recent reports,[4] the combined use of gabapentin and opioids might be an indicator of high-risk opioid misuse and requires further study. In the illicit opioid–only group, the percentage of deaths testing positive for cocaine and methamphetamine is similar to other reports.[5] Finally, extensive use of cocaine and benzodiazepines among deaths where both prescription and illicit opioids were detected highlights the need for prevention and treatment programs to address polysubstance use.[6]

Identification of circumstances surrounding overdose deaths can help inform prevention programs and efforts to target resources. Approximately one in 10 decedents had been released from an institution in the month before the fatal overdose. Rhode Island found that expanding enrollment in a medication-assisted treatment program for incarcerated persons was associated with a 60% decrease in postincarceration overdose deaths.[7] For the 14% of decedents with previous overdoses, there might have been opportunities for linkage to care and treatment services, especially if the overdose involved an emergency department visit.[8] The proportions of decedents with evidence of recent release from an institution and of a previous overdose were higher among deaths involving illicit opioids. Similar to earlier findings,[9] approximately half of the decedents overdosed when bystanders were present. Although distribution of naloxone to laypersons has rapidly expanded and been determined to be effective,††† broader distribution and education about overdose signs and symptoms are needed.

The findings in this report are subject to at least five limitations. First, because there is no national standard for forensic toxicology testing, testing protocols vary across jurisdictions, which affects whether substances were detected. Second, jurisdictions vary in how they classify whether substances with positive toxicology results contribute to death. Third, evidence of overdose-specific circumstances should be interpreted with caution because it relies upon availability of information within medical examiner and coroner reports and focuses on information from a period close to death; thus, prevalence of circumstances is likely underestimated. Fourth, missing information might have resulted in some misclassification of prescription and illicit substance use; however, this was minimized by using detailed toxicology results and scene evidence. Finally, the results are limited to the 11 participating states and cannot be generalized to the United States.

Among 11 states, illicit opioids were a major driver of opioid overdose deaths; however, prescription opioids also contribute to a substantial number of these deaths. Interventions should be guided by the substances detected and contributing to overdose deaths in a given locale and might differ for overdoses involving prescription or illicit opioids, or both. For example, for preventing illicit opioid overdose, integrating public health strategies within public safety (e.g., law enforcement providing linkages to care for persons with substance use disorders), as well as using syringe services programs for naloxone distribution, providing access to treatment, and addressing blood borne infections might have a larger impact. To prevent prescription opioid overdose, strategies might emphasize prescription drug monitoring programs, face-to-face education of prescribers by trained health care professionals, typically pharmacists, physicians, or nurses (a process known as academic detailing), and implementation of the CDC Guideline for Prescribing Opioids for Chronic Pain.[10] However, interventions should not focus exclusively on one opioid type because the epidemic continues to evolve, and use of opioids along with other substances is common. Continued and increased attention should capitalize on opportunities for overdose prevention including linking to treatment during and upon release from an institution or after a nonfatal overdose and expanding naloxone access.

¶¶ http://ajph.aphapublications.org/doi/10.2105/AJPH.2017.304265.
***The Food and Drug Administration issued its strongest warning against combining benzodiazepines with opioids because of risk for overdose. https://www.fda.gov/Drugs/DrugSafety/ucm518473.htm.
††† https://www.bmj.com/content/346/bmj.f174.