Temporal Trends and Geographic Variations in Mortality Rates From Prescription Opioids

Lessons From Florida and West Virginia

Sarah A. Palumbo, BS; Charles H. Hennekens, MD, DrPH; Janet D. Robishaw, PhD; Robert S. Levine, MD


South Med J. 2020;113(3):140-145. 

In This Article

Abstract and Introduction


Objectives: To explore temporal trends and geographic variations in mortality from prescription opioids from 1999 to 2016.

Methods: Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research Multiple Cause of Death files were used to calculate age-adjusted rates and 95% confidence intervals (CIs) and create spatial cluster maps.

Results: From 1999 to 2016, counties in West Virginia experienced the highest overall mortality rates in the United States from prescription opioids. Specifically, from 1999 to 2004, the highest rate in West Virginia of 24.87/100,000 (95% CI 17.84–33.73) was the fourth highest in the United States. From 2005 to 2009, West Virginia experienced the highest rate in the United States, 60.72/100,000 (95% CI 47.33–76.71). From 2010 to 2016, West Virginia also experienced the highest rate in the United States, which was 90.24/100,000 (95% CI 73.11–107.36). As such, overall, West Virginia experienced the highest rates in the United States and the largest increases overall of ~3.6-fold between 1999 and 2004 and 2010 and 2016. From 1999 to 2004, Florida had no "hot spots," but from 2006 to 2010 they did appear, and from 2011 to 2016, they disappeared.

Conclusions: These data show markedly divergent temporal trends and geographic variations in mortality rates from prescription opioids, especially in the southern United States. Specifically, although initial rates were high and continued to increase alarmingly in West Virginia, they increased but then decreased in Florida. These descriptive data generate hypotheses requiring testing in analytic epidemiological studies. Understanding the divergent patterns of prescription opioid-related deaths, especially in West Virginia and Florida, may have important clinical and policy implications.


In the United States, mortality from drug overdoses has become a major contributor to the current highest overall death rates in more than a century. Since 1999, the mortality rates from drug overdoses in the United States have more than tripled.[1] Specifically, deaths from prescription opioids have become a major contributor following the adoption of new standards of pain management, including consideration of pain as a fifth vital sign beginning in 2000.[2,3] These circumstances have contributed, at least in part, to the rapid expansion of both inpatient and outpatient prescription opioid use. These circumstances also have contributed to the increased occurrence of opioid use disorder (OUD) and alarming increasing mortality rates from prescription opioids.[2]

In the context of overall opioid prescribing history, the Harrison Narcotics Tax Act of 1914 (Public Law 63–223) outlined laws and taxes intended to regulate opioid distribution.[2] In 1961, the Single Convention on Narcotic Drugs established criteria for countries that included restrictions on the prescription of opioids.[4] Healthcare providers rarely prescribed opioids because of concerns about addiction. In 1986, however, on the basis primarily of the desire to humanly manage the pain of patients with cancer, the World Health Organization identified the pain treatment as a universal right and developed cancer pain treatment guidelines.[2]

With the release of the report from The Joint Commission, pain began to be considered the fifth vital sign. In addition, more aggressive treatment of chronic pain through the expanded prescription of opioids was promoted by opioid manufacturers. For example, in 1996, Purdue Pharma began to market OxyContin, claiming, "Minimal risk for iatrogenic addiction."[5,6] From 1998 to 2000, successful marketing campaigns led to the expanded prescription of opioids throughout the United States. In some states such as Alabama, Kentucky, Maine, Virginia, and West Virginia, opioid prescription levels already were 2.5 to 5 times higher than the national average, and the introduction of OxyContin led to prescription rates that were 5 to 6 times higher. An epidemic of prescription opioid-related mortality followed.[6]

Between 2010 and 2012, opioid prescriptions were at their highest in the United States.[7] Although generally declining since then, the dosage of opioids prescribed in morphine milligram equivalents remains about 3 times higher in 2017 than it was in 1999.[7] In addition, from 2002 to 2015, there was a 2.6-fold increase in the number of prescription opioid overdoses and a 5.6-fold increase in synthetic opioid deaths not including methadone.[8] Drug overdoses accounted for approximately 70,000 annual premature deaths in 2017, nearly 68% of which involved an opioid.[9] Finally, although the opioid epidemic is a national health crisis, some areas of the United States are disproportionately affected. The availability of mortality data from the Centers for Disease Control and Prevention (CDC) afforded a unique opportunity to explore temporal trends and geographic variations in mortality from prescription opioids.