Abstract and Introduction
From 2013 to 2017, the number of opioid-involved overdose deaths (opioid deaths) in the United States increased 90%, from 25,052 to 47,600.* This increase was primarily driven by substantial increases in deaths involving illicitly manufactured fentanyl (IMF) or fentanyl analogs† mixed with heroin, sold as heroin, or pressed into counterfeit prescription pills.[1–3] Methamphetamine-involved and cocaine-involved deaths that co-involved opioids also substantially increased from 2016 to 2017. Provisional 2018§ estimates of the number of opioid deaths suggest a small decrease from 2017. Investigating the extent to which decreases occurred broadly or were limited to a subset of opioid types (e.g., prescription opioids versus IMF) and drug combinations (e.g., IMF co-involving cocaine) can assist in targeting of intervention efforts. This report describes opioid deaths during January–June 2018 and changes from July–December 2017 in 25¶ of 32 states and the District of Columbia participating in CDC's State Unintentional Drug Overdose Reporting System (SUDORS).** Opioid deaths were analyzed by involvement (opioid determined by medical examiner or coroner to contribute to overdose death) of prescription or illicit opioids,†† as well as by the presence (detection of the drug in decedent) of co-occurring nonopioid drugs (cocaine, methamphetamine, and benzodiazepines). Three key findings emerged regarding changes in opioid deaths from July–December 2017 to January–June 2018. First, overall opioid deaths decreased 4.6%. Second, decreases occurred in prescription opioid deaths without co-involved illicit opioids and deaths involving non-IMF illicit synthetic opioids (fentanyl analogs and U-series drugs). Third, IMF deaths, especially those with multiple illicit opioids and common nonopioids, increased. Consequently, IMF was involved in approximately two-thirds of opioid deaths during January–June 2018. Notably, during January–June 2018, 62.6% of all opioid deaths co-occurred with at least one common nonopioid drug. To maintain and accelerate reductions in opioid deaths, efforts to prevent IMF-involved deaths and address polysubstance misuse with opioids must be enhanced. Key interventions include broadening outreach to groups at high risk for IMF or fentanyl analog exposure and overdose. Improving linkage to and engagement in risk-reduction services and evidence-based treatment for persons with opioid and other substance use disorders with attention to polysubstance use or misuse is also needed.
Numbers of opioid deaths of unintentional and undetermined intent§§ occurring during January–June 2018 and changes from July–December 2017 were analyzed for 25 of the 32 states and the District of Columbia that participate in SUDORS (data for these periods were the most recent and complete). The states abstract death certificate and medical examiner and coroner report data, including death scene investigation and toxicology findings. States list drugs involved in (i.e., contributing to) the opioid death as determined by medical examiners and coroners¶¶ and all drugs detected (present or co-occurring) by toxicologic tests. Fentanyl and morphine deaths were classified as prescription opioid deaths or illicit opioid deaths based on scene evidence and toxicology findings.*** Changes in the number of opioid deaths from July–December 2017 to January–June 2018 were analyzed by five opioid types†††: 1) prescription, 2) IMF, 3) fentanyl analog, 4) heroin, and 5) U-series. Because the frequency and changes in opioid deaths might vary by co-involvement with IMF or other illicit opioids, opioid deaths were also grouped into the following eight mutually exclusive categories: 1) IMF with no other illicit opioids involved; 2) IMF co-involving heroin; 3) IMF co-involving fentanyl analogs; 4) co-involved IMF, heroin, and fentanyl analogs; 5) heroin with no other illicit opioids involved; 6) fentanyl analogs with no other illicit opioids involved; 7) prescription opioids with no illicit opioids involved; and 8) all other opioid combinations. Finally, deaths were analyzed by nonopioids (cocaine, methamphetamine, and benzodiazepines) that are commonly present and involved in opioid deaths.§§§ Tracking the presence of commonly occurring nonopioids is important to inform public health action and has implications for treatment approaches. Some opioid deaths were grouped into one or more of the five opioid type categories and nonopioid drug combinations because multiple opioids and nonopioids might be involved in a single death (e.g., an opioid death involving IMF, heroin, cocaine, and a benzodiazepine). Changes in numbers of opioid deaths over the analysis period were tested using z-tests or nonoverlapping confidence intervals if the number of deaths was <100. SAS statistical software (version 9.4; SAS Institute, Inc.) was used for all analyses; p-values <0.05 were considered statistically significant.¶¶¶
During January–June 2018, among 13,631 opioid deaths in the 25 states, data on specific opioids involved were available for 13,415 (98.4%). IMF was co-involved in 68.0% of 5,281 heroin deaths and most (82.1%) of 2,678 fentanyl analog deaths (Table 1). In addition, 1,562 (40.5%) of 3,853 prescription opioid deaths co-involved illicit opioids. Opioids commonly involved in opioid deaths were IMF (67.9%), heroin (39.4%), prescription opioids (28.7%), and fentanyl analogs (20.0%) (Table 2). Among categories of deaths involving IMF, those with no other illicit opioids involved, those co-involved with heroin, those co-involved with fentanyl analogs, and those co-involved with heroin and fentanyl analogs accounted for 32.2%, 19.1%, 8.7%, and 7.5% of deaths, respectively. Heroin without other illicit opioids involved accounted for 11.4% of deaths, fentanyl analogs with no other illicit opioids involved for 2.3%, prescription opioids with no illicit opioids involved for 17.1%, and all other opioid combinations for 1.6%. In the Midwest, Northeast, and South U.S. Census regions, deaths involving any IMF were more common than were those involving any heroin. In the West, heroin-involved deaths (47.5%) were more common than were IMF-involved deaths (15.8%) (data not shown).
Three principal changes occurred in opioid deaths from July–December 2017 to January–June 2018. First, overall opioid deaths in the 25 states declined by 4.6% (Table 2). Second, declines occurred in prescription opioid deaths with no co-involved illicit opioids (10.6%) and non-IMF illicit synthetic opioid deaths, including fentanyl analogs (19.0% decline) and U-series drugs (75.1% decline). With the exception of acetylfentanyl, decreases in fentanyl analog deaths occurred broadly across all fentanyl analogs (52.7% decline). Acetylfentanyl deaths co-involving IMF showed a sharp increase (57.5%). Third, IMF deaths increased by 11.1% overall, with increases of 9.5%–33.0% in those co-involving other illicit opioids and 9.4% among those with no other illicit opioids involved. Illicit opioid overdose deaths involving heroin and fentanyl analogs increased when IMF was co-involved, but decreased when IMF and other illicit opioids were not co-involved. Specifically, increases occurred in IMF deaths co-involving heroin (9.5%), fentanyl analogs (11.4%), and both heroin and fentanyl analogs (33.0%). In contrast, substantial declines were observed in heroin deaths with no other illicit opioids involved (16.6% decline) and fentanyl analog deaths with no other illicit opioids involved (67.9% decline). Declines in heroin deaths with no other illicit opioids involved were offset by increases in heroin deaths co-involving IMF, resulting in no significant change in heroin deaths.
The majority of opioid deaths (62.6%) co-occurred with one or more of the following drugs: benzodiazepines, cocaine, and methamphetamine, which were each present in 32.5%, 34.0%, and 12.1% of deaths, respectively. From July–December 2017 to January–June 2018, opioid deaths without benzodiazepines, cocaine, or methamphetamine decreased 8.0%, and opioid deaths co-occurring with benzodiazepines significantly decreased 5.7% (Table 3). Conversely, opioid deaths co-occurring with methamphetamine significantly increased by 14.6%. IMF deaths that co-occurred with benzodiazepines, cocaine, and methamphetamine significantly increased from July–December 2017 to January–June 2018 by 11.3%, 14.0%, and 31.0%, respectively, as IMF deaths without benzodiazepines, cocaine, or methamphetamine increased 6.7%.
Morbidity and Mortality Weekly Report. 2019;68(34):737-744. © 2019 Centers for Disease Control and Prevention (CDC)