Antihistamine Positivity and Involvement in Drug Overdose Deaths

Abbreviations: IMFs = illicitly manufactured fentanyls; SUDORS = State Unintentional Drug Overdose Reporting System.
*Drug entries coded as antihistamines in SUDORS were allergy, allergy relief, antihistamines, Atarax, Benadryl, brompheniramine, carbinoxamine, cetirizine or cetirizine metabolite, chlorcyclizine or chlorcyclizine metabolite, chlorpheniramine or chlorpheniramine metabolite, cyproheptadine or cyproheptadine metabolite, desalkylhydroxyzine, descarboethoxyloratadine, desloratadine, dexbrompheniramine, dexchlorpheniramine, diphenhydramine or diphenhydramine metabolite, doxylamine or doxylamine metabolite, fexofenadine, hydroxyzine or hydroxyzine metabolite, hydroxyzine/cetirizine/meclizine (not distinguished) metabolite, levocetirizine, loratadine, mereprine, norchlorcyclizine, norcyproheptadine, nordiphenhydramine, norhydroxyzine norpromethazine, Nytol, phenergan, pheniramine, phenyltoloxamine, promethazine or promethazine metabolite, pyrilamine, tripelennamine, triprolidine, Unisom, Vistaril, and Zyrtec.
^†SUDORS captures data on fatal unintentional and undetermined intent overdoses. For all captured overdose deaths, SUDORS records all drugs detected by postmortem toxicology, even those not ruled by a medical examiner or coroner as causing death. A drug was recorded as positive when it was detected on postmortem toxicology or listed as a cause of death on the death certificate. A drug was recorded as involved when it was listed as a cause of death on the death certificate. The medical examiner or coroner lists drugs on the death certificate based on any of the following: postmortem toxicology detection, evidence of drug use at the scene, or witness reports of drug use.
^§Among 48 funded jurisdictions, 43 states and the District of Columbia reported data during January 2019–December 2020. Twenty-six jurisdictions reported deaths that occurred during the entire period: Alaska, Connecticut, Delaware, District of Columbia, Georgia, Illinois, Kentucky, Maine, Massachusetts, Minnesota, Missouri, Nevada, New Hampshire, New Jersey, New Mexico, North Carolina, Ohio, Oklahoma, Pennsylvania, Rhode Island, Tennessee, Utah, Vermont, Virginia, Washington, and West Virginia. Eighteen additional jurisdictions reported deaths during at least one 6-month period during January 2019–December 2020 (i.e., January–June 2019, July–December 2019, January–June 2020, or July–December 2020): Alabama, Arizona, Arkansas, Colorado, Florida, Hawaii, Indiana, Iowa, Kansas, Louisiana, Maryland, Michigan, Mississippi, Montana, Nebraska, Oregon, South Dakota, and Wisconsin. Fifteen jurisdictions reported deaths from counties that accounted for ≥75% of drug overdose deaths in the state in 2017 for at least one 6-month period per SUDORS funding requirements (Alabama, Arkansas, Colorado, Florida, Hawaii, Illinois, Indiana, Louisiana, Michigan, Missouri, Nebraska, Pennsylvania, South Dakota, Washington, and Wisconsin); all other jurisdictions reported deaths from the full jurisdiction. Data were current as of April 25, 2022.
^¶Age data were missing for one decedent.
**Includes non-Hispanic American Indian or Alaska Native, non-Hispanic Asian or Pacific Islander, or non-Hispanic multiracial persons.
^††https://www2.census.gov/geo/pdfs/maps-data/maps/reference/us_regdiv.pdf
^§§Identified as a cause of death by a medical examiner or coroner.
^¶¶Multiple drugs could be listed as a cause of death; therefore, drugs are not mutually exclusive.
***IMFs include illicitly manufactured fentanyl and illicit fentanyl analogs, which were identified using both toxicology and scene evidence because toxicology alone cannot distinguish between pharmaceutical fentanyl and IMFs.
^†††Drug entries coded as heroin in SUDORS were heroin and 6-acetylmorphine. In addition, morphine was coded as heroin if detected along with 6-acetylmorphine or if scene, toxicology, or witness evidence indicated presence of known heroin adulterants or impurities (including quinine, procaine, xylazine, noscapine, papaverine, thebaine, or acetylcodeine), injection, illicit drug use, or a history of heroin use.
^§§§Drug entries coded as prescription opioids in SUDORS were alfentanil, buprenorphine, butorphanol, codeine, dextrorphan, dihydrocodeine, hydrocodone, hydromorphone, levorphanol, loperamide, meperidine, methadone, morphine, nalbuphine, noscapine, oxycodone, oxymorphone, pentazocine, prescription fentanyl, propoxyphene, sufentanil, tapentadol, and tramadol. Also included as prescription opioids were brand names and metabolites (e.g., nortramadol) of these drugs and combinations of these drugs and nonopioids (e.g., acetaminophen-oxycodone). Morphine was included as prescription only if scene or witness evidence did not indicate likely heroin use and if 6-acetylmorphine was not also detected. Fentanyl was coded as a prescription opioid based on scene, toxicology, or witness evidence.
^¶¶¶Includes antihistamine-positive deaths with antihistamines as only drug positive, antihistamine-involved deaths with antihistamines as only drug involved, diphenhydramine-positive deaths with diphenhydramine as only drug positive, and diphenhydramine-involved deaths with diphenhydramine as only drug involved.

Authors and Disclosures

Amanda T. Dinwiddie, MPH¹, Lauren J. Tanz, ScD¹ and Jessica Bitting, MS<sup>1,2

1</sup>Division of Overdose Prevention, National Center for Injury Prevention and Control, CDC; ²National Network of Public Health Institutes, Washington, D.C.

Corresponding author
Amanda T. Dinwiddie, qpv6@cdc.gov, 404-498-4128.

All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.