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      Epidemiological trends in opioid-only and opioid/polysubstance-related death rates among American Indian/Alaska Native populations from 1999 to 2019: a retrospective longitudinal ecological study

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          Abstract

          Objectives

          The rate of drug overdose deaths in the USA has more than tripled since the turn of the century, and rates are disproportionately high among the American Indian/Alaska Native (AI/AN) population. Little is known about the overall historical trends in AI/AN opioid-only and opioid/polysubstance-related mortality. This study will address this gap.

          Design

          This is a retrospective longitudinal ecological study.

          Setting

          US death records from 1999 to 2019 using the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research.

          Participants

          US non-Hispanic AI/AN people age 12 years and older.

          Measures

          The primary outcomes, identified via the 10th revision of the International Statistical Classification of Diseases and Related Health Problems codes, included overdose deaths due to (1) opioids only, opioids in combination with any other substance, all-opioid related overdoses; (2) combinations of opioids and alcohol, opioids and methamphetamine, opioids and cocaine, opioids and benzodiazepines; and (3) specific types of opioids.

          Results

          From 1999 to 2019, opioid-only mortality rates increased from 2.8 to 15.8 per 100 000 (p<0.001) for AI/AN women and 4.6 to 25.6 per 100 000 (p<0.001) for AI/AN men. All opioid-related mortality rates increased significantly (p<0.001) from 5.2 to 33.9 per 100 000 AI/AN persons, 3.9 to 26.1 for women and 6.5 to 42.1 for men. AI/AN also exhibited significant increases in mortality rates due to opioids and alcohol, opioids and benzodiazepines, opioids and methamphetamine, and AI/AN men experienced substantial increases in mortality due to opioids and cocaine. Mortality rates by individual opioid types increased significantly over time for heroin, natural and semi-synthetic (prescription), and synthetic opioids (fentanyl/fentanyl analogues) other than methadone.

          Conclusions

          These findings highlight magnification over time in opioid-related deaths and may point to broader systemic factors that may disproportionately affect members of AI/AN communities and drive inequities.

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          Most cited references36

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          Traumatic Brain Injury–Related Emergency Department Visits, Hospitalizations, and Deaths — United States, 2007 and 2013

          Problem/Condition Traumatic brain injury (TBI) has short- and long-term adverse clinical outcomes, including death and disability. TBI can be caused by a number of principal mechanisms, including motor-vehicle crashes, falls, and assaults. This report describes the estimated incidence of TBI-related emergency department (ED) visits, hospitalizations, and deaths during 2013 and makes comparisons to similar estimates from 2007. Reporting Period 2007 and 2013. Description of System State-based administrative health care data were used to calculate estimates of TBI-related ED visits and hospitalizations by principal mechanism of injury, age group, sex, and injury intent. Categories of injury intent included unintentional (motor-vehicle crashes, falls, being struck by or against an object, mechanism unspecified), intentional (self-harm and assault/homicide), and undetermined intent. These health records come from the Healthcare Cost and Utilization Project’s National Emergency Department Sample and National Inpatient Sample. TBI-related death analyses used CDC multiple-cause-of-death public-use data files, which contain death certificate data from all 50 states and the District of Columbia. Results In 2013, a total of approximately 2.8 million TBI-related ED visits, hospitalizations, and deaths (TBI-EDHDs) occurred in the United States. This consisted of approximately 2.5 million TBI-related ED visits, approximately 282,000 TBI-related hospitalizations, and approximately 56,000 TBI-related deaths. TBIs were diagnosed in nearly 2.8 million (1.9%) of the approximately 149 million total injury- and noninjury-related EDHDs that occurred in the United States during 2013. Rates of TBI-EDHDs varied by age, with the highest rates observed among persons aged ≥75 years (2,232.2 per 100,000 population), 0–4 years (1,591.5), and 15–24 years (1,080.7). Overall, males had higher age-adjusted rates of TBI-EDHDs (959.0) compared with females (810.8) and the most common principal mechanisms of injury for all age groups included falls (413.2, age-adjusted), being struck by or against an object (142.1, age-adjusted), and motor-vehicle crashes (121.7, age-adjusted). The age-adjusted rate of ED visits was higher in 2013 (787.1) versus 2007 (534.4), with fall-related TBIs among persons aged ≥75 years accounting for 17.9% of the increase in the number of TBI-related ED visits. The number and rate of TBI-related hospitalizations also increased among persons aged ≥75 years (from 356.9 in 2007 to 454.4 in 2013), primarily because of falls. Whereas motor-vehicle crashes were the leading cause of TBI-related deaths in 2007 in both number and rate, in 2013, intentional self-harm was the leading cause in number and rate. The overall age-adjusted rate of TBI-related deaths for all ages decreased from 17.9 in 2007 to 17.0 in 2013; however, age-adjusted TBI-related death rates attributable to falls increased from 3.8 in 2007 to 4.5 in 2013, primarily among older adults. Although the age-adjusted rate of TBI-related deaths attributable to motor-vehicle crashes decreased from 5.0 in 2007 to 3.4 in 2013, the age-adjusted rate of TBI-related ED visits attributable to motor-vehicle crashes increased from 83.8 in 2007 to 99.5 in 2013. The age-adjusted rate of TBI-related hospitalizations attributable to motor-vehicle crashes decreased from 23.5 in 2007 to 18.8 in 2013. Interpretation Progress has been made to prevent motor-vehicle crashes, resulting in a decrease in the number of TBI-related hospitalizations and deaths from 2007 to 2013. However, during the same time, the number and rate of older adult fall-related TBIs have increased substantially. Although considerable public interest has focused on sports-related concussion in youth, the findings in this report suggest that TBIs attributable to older adult falls, many of which result in hospitalization and death, should receive public health attention. Public Health Actions The increase in the number of fall-related TBIs in older adults suggests an urgent need to enhance fall-prevention efforts in that population. Multiple effective interventions have been identified, and CDC has developed the STEADI initiative (Stopping Elderly Accidents Deaths and Injuries) as a comprehensive strategy that incorporates empirically supported clinical guidelines and scientifically tested interventions to help primary care providers address their patients’ fall risk through the identification of modifiable risk factors and implementation of effective interventions (e.g., exercise, medication management, and Vitamin D supplementation).
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            Drug and Opioid-Involved Overdose Deaths — United States, 2017–2018

            Of the 70,237 drug overdose deaths in the United States in 2017, approximately two thirds (47,600) involved an opioid ( 1 ). In recent years, increases in opioid-involved overdose deaths have been driven primarily by deaths involving synthetic opioids other than methadone (hereafter referred to as synthetic opioids) ( 1 ). CDC analyzed changes in age-adjusted death rates from 2017 to 2018 involving all opioids and opioid subcategories* by demographic characteristics, county urbanization levels, U.S. Census region, and state. During 2018, a total of 67,367 drug overdose deaths occurred in the United States, a 4.1% decline from 2017; 46,802 (69.5%) involved an opioid ( 2 ). From 2017 to 2018, deaths involving all opioids, prescription opioids, and heroin decreased 2%, 13.5%, and 4.1%, respectively. However, deaths involving synthetic opioids increased 10%, likely driven by illicitly manufactured fentanyl (IMF), including fentanyl analogs ( 1 , 3 ). Efforts related to all opioids, particularly deaths involving synthetic opioids, should be strengthened to sustain and accelerate declines in opioid-involved deaths. Comprehensive surveillance and prevention measures are critical to reducing opioid-involved deaths, including continued surveillance of evolving drug use and overdose, polysubstance use, and the changing illicit drug market; naloxone distribution and outreach to groups at risk for IMF exposure; linkage to evidence-based treatment for persons with substance use disorders; and continued partnerships with public safety. Drug overdose deaths were identified in National Vital Statistics System multiple cause-of-death mortality files † using the International Classification of Diseases, Tenth Revision (ICD-10) underlying cause-of-death codes X40–X44 (unintentional), X60–X64 (suicide), X85 (homicide), or Y10–Y14 (undetermined intent). Among deaths with drug overdose as the underlying cause, the opioid subcategory was determined by the following ICD-10 multiple cause-of-death codes: all opioids (T40.0, T40.1, T40.2, T40.3, T40.4, or T40.6) § ; prescription opioids (T40.2 or T40.3); heroin (T40.1); and synthetic opioids other than methadone (T40.4). Some deaths involved more than one opioid subcategory and were included in the rates for each; subcategories are not mutually exclusive. ¶ Changes from 2017 to 2018 in age-adjusted overdose death rates** were examined for all opioids, prescription opioids, heroin, and synthetic opioids. Death rates were stratified by age, sex, race/ethnicity, urbanization level, †† U.S. Census region, §§ and state. State-level analyses included 38 states and the District of Columbia (DC) with adequate drug specificity ¶¶ for 2017 and 2018.*** The drug or drugs involved in the drug overdose death were not specified on 12% of drug overdose death certificates in 2017 and on 8% of those from 2018. The percentage of 2018 death certificates with at least one drug specified ranged from 54.1% to 100% among states. Changes in death rates from 2017 to 2018 were compared using z-tests when deaths were ≥100 and nonoverlapping confidence intervals based on a gamma distribution when <100. ††† Changes presented in the text represent statistically significant findings, unless otherwise specified. During 2018, drug overdoses resulted in 67,367 deaths in the United States, a 4.1% decrease from 2017. Among these drug overdose deaths, 46,802 (69.5%) involved an opioid. From 2017 to 2018, opioid-involved death rates decreased 2.0%, from 14.9 per 100,000 population to 14.6 (Table 1); decreases occurred among females; persons aged 15–34 years and 45–54 years; non-Hispanic whites; and in small metro, micropolitan, and noncore areas; and in the Midwest and South regions. Rates during 2017–2018 increased among persons aged ≥65 years, non-Hispanic blacks, and Hispanics, and in the Northeast and the West regions. Rates decreased in 11 states and DC and increased in three states, with the largest relative (percentage) decrease in Iowa (–30.4%) and the largest absolute decrease (difference in rates) in Ohio (–9.6); the largest relative and absolute increase occurred in Missouri (18.8%, 3.1). The highest opioid-involved death rate in 2018 was in West Virginia (42.4 per 100,000). TABLE 1 Annual number and age-adjusted rate of drug overdose deaths* involving all opioids † and prescription opioids, § , ¶ by sex, age, race/ethnicity,** urbanization level, †† U.S. Census region, §§ and selected states ¶¶ — National Vital Statistics System, United States, 2017 and 2018 Decedent characteristic All opioids Prescription opioids 2017 2018 Rate change from 2017 to 2018*** 2017 2018 Rate change from 2017 to 2018*** No. (rate) No. (rate) Absolute change Relative change No. (rate) No. (rate) Absolute change Relative change All 47,600 (14.9) 46,802 (14.6) −0.3††† −2.0††† 17,029 (5.2) 14,975 (4.5) −0.7††† −13.5††† Sex Male 32,337 (20.4) 32,078 (20.1) −0.3 −1.5 9,873 (6.1) 8,723 (5.3) −0.8 ††† −13.1 ††† Female 15,263 (9.4) 14,724 (9.0) −0.4 ††† −4.3 ††† 7,156 (4.2) 6,252 (3.7) −0.5 ††† −11.9 ††† Age group (yrs) 0–14 79 (0.1) 65 (0.1) 0.0 0.0 50 (0.1) 36 (0.1) 0.0 0.0 15–24 4,094 (9.5) 3,618 (8.4) −1.1 ††† −11.6 ††† 1,050 (2.4) 790 (1.8) −0.6 ††† −25.0 ††† 25–34 13,181 (29.1) 12,839 (28.1) −1.0 ††† −3.4 ††† 3,408 (7.5) 2,862 (6.3) −1.2 ††† −16.0 ††† 35–44 11,149 (27.3) 11,414 (27.7) 0.4 1.5 3,714 (9.1) 3,350 (8.1) −1.0 ††† −11.0 ††† 45–54 10,207 (24.1) 9,565 (23.0) −1.1 ††† −4.6 ††† 4,238 (10.0) 3,490 (8.4) −1.6 ††† −16.0 ††† 55–64 7,153 (17.0) 7,278 (17.2) 0.2 1.2 3,509 (8.4) 3,291 (7.8) −0.6 ††† −7.1 ††† ≥65 1,724 (3.4) 2,012 (3.8) 0.4 ††† 11.8 ††† 1,055 (2.1) 1,152 (2.2) 0.1 4.8 Sex and age group (yrs) Male 15–24 2,885 (13.0) 2,527 (11.5) −1.5 ††† −11.5 ††† 728 (3.3) 548 (2.5) −0.8 ††† −24.2 ††† Male 25–44 17,352 (40.0) 17,240 (39.4) −0.6 −1.5 4,516 (10.4) 3,895 (8.9) −1.5 ††† −14.4 ††† Male 45–64 11,061 (26.9) 10,986 (26.8) −0.1 −0.4 4,089 (9.9) 3,637 (8.9) −1.0 ††† −10.1 ††† Female 15–24 1,209 (5.7) 1,091 (5.2) −0.5 ††† −8.8 ††† 322 (1.5) 242 (1.2) −0.3 ††† −20.0 ††† Female 25–44 6,978 (16.3) 7,013 (16.2) −0.1 −0.6 2,606 (6.1) 2,317 (5.4) −0.7 ††† −11.5 ††† Female 45–64 6,299 (14.6) 5,857 (13.6) −1.0 ††† −6.8 ††† 3,658 (8.5) 3,144 (7.3) −1.2 ††† −14.1 ††† Race/Ethnicity** White, non-Hispanic 37,113 (19.4) 35,363 (18.6) −0.8 ††† −4.1 ††† 13,900 (6.9) 12,085 (6.0) −0.9 ††† −13.0 ††† Black, non-Hispanic 5,513 (12.9) 6,088 (14.0) 1.1 ††† 8.5 ††† 1,508 (3.5) 1,444 (3.3) −0.2 −5.7 Hispanic 3,932 (6.8) 4,370 (7.5) 0.7 ††† 10.3 ††† 1,211 (2.2) 1,122 (2.0) −0.2 ††† −9.1 ††† American Indian/Alaska Native, non-Hispanic 408 (15.7) 373 (14.2) −1.5 −9.6 187 (7.2) 125 (4.7) −2.5 ††† −34.7 ††† Asian/Pacific Islander, non-Hispanic 348 (1.6) 345 (1.5) −0.1 −6.3 130 (0.6) 115 (0.5) −0.1 −16.7 County urbanization level†† Large central metro 14,518 (13.9) 14,767 (14.1) 0.2 1.4 4,945 (4.7) 4,394 (4.1) −0.6 ††† −12.8 ††† Large fringe metro 13,594 (17.2) 13,476 (17.0) −0.2 −1.2 4,273 (5.2) 3,791 (4.6) −0.6 ††† −11.5 ††† Medium metro 10,561 (16.2) 10,328 (15.8) −0.4 −2.5 3,951 (5.9) 3,539 (5.2) −0.7 ††† −11.9 ††† Small metro 3,560 (12.9) 3,379 (12.2) −0.7 ††† −5.4 ††† 1,479 (5.2) 1,278 (4.5) −0.7 ††† −13.5 ††† Micropolitan (nonmetro) 3,462 (13.9) 3,162 (12.7) −1.2 ††† −8.6 ††† 1,440 (5.6) 1,240 (4.7) −0.9 ††† −16.1 ††† Noncore (nonmetro) 1,905 (11.2) 1,690 (10.1) −1.1 ††† −9.8 ††† 941 (5.3) 733 (4.1) −1.2 ††† −22.6 ††† U.S. Census region of residence§§ Northeast 11,784 (21.3) 12,467 (22.8) 1.5 ††† 7.0 ††† 3,047 (5.3) 2,991 (5.3) 0.0 0.0 Midwest 12,483 (19.1) 11,268 (17.2) −1.9 ††† −9.9 ††† 3,702 (5.5) 2,965 (4.4) −1.1 ††† −20.0 ††† South 16,999 (14.1) 16,413 (13.5) −0.6 ††† −4.3 ††† 6,929 (5.6) 5,936 (4.7) −0.9 ††† −16.1 ††† West 6,334 (8.0) 6,654 (8.3) 0.3 ††† 3.8 ††† 3,351 (4.1) 3,083 (3.8) −0.3 ††† −7.3 ††† States with very good to excellent reporting (n = 29)¶¶ Alaska 102 (13.9) 68 (8.8) −5.1 −36.7 51 (7.0) 38 (4.9) −2.1 −30.0 Arizona 928 (13.5) 1,106 (15.9) 2.4 ††† 17.8 ††† 414 (5.9) 362 (5.0) −0.9 ††† −15.3 ††† Connecticut 955 (27.7) 948 (27.5) −0.2 −0.7 273 (7.7) 231 (6.4) −1.3 −16.9 District of Columbia 244 (34.7) 191 (26.7) −8.0 ††† −23.1 ††† 58 (8.4) 41 (5.7) −2.7 −32.1 Georgia 1,014 (9.7) 866 (8.3) −1.4 ††† −14.4 ††† 568 (5.4) 440 (4.1) −1.3 ††† −24.1 ††† Illinois 2,202 (17.2) 2,169 (17.0) −0.2 −1.2 623 (4.8) 539 (4.2) −0.6 ††† −12.5 ††† Iowa 206 (6.9) 143 (4.8) −2.1 ††† −30.4 ††† 104 (3.4) 64 (2.1) −1.3 ††† −38.2 ††† Maine 360 (29.9) 282 (23.4) −6.5 ††† −21.7 ††† 100 (7.6) 69 (5.1) −2.5 −32.9 Maryland 1,985 (32.2) 2,087 (33.7) 1.5 4.7 711 (11.5) 576 (9.2) −2.3 ††† −20.0 ††† Massachusetts 1,913 (28.2) 1,991 (29.3) 1.1 3.9 321 (4.6) 331 (4.7) 0.1 2.2 Missouri 952 (16.5) 1,132 (19.6) 3.1 ††† 18.8 ††† 253 (4.1) 265 (4.4) 0.3 7.3 Nevada 412 (13.3) 372 (11.5) −1.8 −13.5 276 (8.7) 235 (7.2) −1.5 ††† −17.2 ††† New Hampshire 424 (34.0) 412 (33.1) −0.9 −2.6 62 (4.8) 43 (3.1) −1.7 −35.4 New Mexico 332 (16.7) 338 (16.7) 0.0 0.0 171 (8.5) 176 (8.2) −0.3 −3.5 New York 3,224 (16.1) 2,991 (15.1) −1.0 ††† −6.2 ††† 1,044 (5.1) 998 (4.9) −0.2 −3.9 North Carolina 1,953 (19.8) 1,783 (17.9) −1.9 ††† −9.6 ††† 659 (6.5) 489 (4.7) −1.8 ††† −27.7 ††† Ohio 4,293 (39.2) 3,237 (29.6) −9.6 ††† −24.5 ††† 947 (8.4) 571 (5.0) −3.4 ††† −40.5 ††† Oklahoma 388 (10.2) 308 (7.8) −2.4 ††† −23.5 ††† 251 (6.7 172 (4.3) −2.4 ††† −35.8 ††† Oregon 344 (8.1) 339 (8.0) −0.1 −1.2 154 (3.5) 151 (3.4) −0.1 −2.9 Rhode Island 277 (26.9) 267 (25.9) −1.0 −3.7 99 (8.8) 85 (7.7) −1.1 −12.5 South Carolina 749 (15.5) 835 (17.1) 1.6 10.3 345 (7.1) 375 (7.4) 0.3 4.2 Tennessee 1,269 (19.3) 1,307 (19.9) 0.6 3.1 644 (9.6) 550 (8.2) −1.4 ††† −14.6 ††† Utah 456 (15.5) 437 (14.8) −0.7 −4.5 315 (10.8) 306 (10.5) −0.3 −2.8 Vermont 114 (20.0) 127 (22.8) 2.8 14.0 40 (6.3) 27 (4.4) −1.9 −30.2 Virginia 1,241 (14.8) 1,193 (14.3) −0.5 −3.4 404 (4.7) 326 (3.8) −0.9 ††† −19.1 ††† Washington 742 (9.6) 737 (9.4) −0.2 −2.1 343 (4.3) 301 (3.8) −0.5 −11.6 West Virginia 833 (49.6) 702 (42.4) −7.2 ††† −14.5 ††† 304 (17.2) 234 (13.1) −4.1 ††† −23.8 ††† Wisconsin 926 (16.9) 846 (15.3) −1.6 ††† −9.5 ††† 362 (6.4) 301 (5.3) −1.1 ††† −17.2 ††† Wyoming 47 (8.7) 40 (6.8) −1.9 −21.8 31 (6.0) 28 (4.6) −1.4 −23.3 States with good reporting (n = 10)¶¶ California 2,199 (5.3) 2,410 (5.8) 0.5 ††† 9.4 ††† 1,169 (2.8) 1,084 (2.6) −0.2 −7.1 Colorado 578 (10.0) 564 (9.5) −0.5 −5.0 300 (5.1) 268 (4.4) −0.7 −13.7 Florida 3,245 (16.3) 3,189 (15.8) −0.5 −3.1 1,272 (6.0) 1,282 (6.0) 0.0 0.0 Hawaii 53 (3.4) 59 (4.1) 0.7 20.6 40 (2.5) 33 (2.3) −0.2 −8.0 Indiana 1,176 (18.8) 1,104 (17.5) −1.3 −6.9 425 (6.6) 370 (5.6) −1.0 ††† −15.2 ††† Kentucky 1,160 (27.9) 989 (23.4) −4.5 ††† −16.1 ††† 433 (10.2) 315 (7.2) −3.0 ††† −29.4 ††† Michigan 2,033 (21.2) 2,011 (20.8) −0.4 −1.9 633 (6.5) 556 (5.6) −0.9 ††† −13.8 ††† Minnesota 422 (7.8) 343 (6.3) −1.5 ††† −19.2 ††† 195 (3.6) 136 (2.5) −1.1 ††† −30.6 ††† Mississippi 185 (6.4) 173 (6.1) −0.3 −4.7 96 (3.2) 92 (3.1) −0.1 −3.1 Texas 1,458 (5.1) 1,402 (4.8) −0.3 −5.9 646 (2.3) 547 (1.9) −0.4 −17.4 * Deaths were classified using the International Classification of Diseases, Tenth Revision (ICD–10). Drug overdose deaths were identified using underlying cause-of-death codes X40–X44, X60–X64, X85, and Y10–Y14. Rates are age-adjusted using the direct method and the 2000 U.S. standard population, except for age-specific crude rates. All rates are per 100,000 population. † Drug overdose deaths, as defined, that have opium (T40.0), heroin (T40.1), natural and semisynthetic opioids (T40.2), methadone (T40.3), synthetic opioids other than methadone (T40.4) or other and unspecified narcotics (T40.6) as a contributing cause. § Drug overdose deaths, as defined, that have natural and semisynthetic opioids (T40.2) or methadone (T40.3) as a contributing cause. ¶ Categories of deaths are not exclusive as deaths might involve more than one drug category. Summing of categories will result in more than the total number of deaths in a year. ** Data for Hispanic origin should be interpreted with caution; studies comparing Hispanic origin on death certificates and on Census surveys have shown inconsistent reporting on Hispanic ethnicity. Potential race misclassification might lead to underestimates for certain categories, primarily American Indian/Alaska Native non-Hispanic and Asian/Pacific Islander non-Hispanic decedents. https://www.cdc.gov/nchs/data/series/sr_02/sr02_172.pdf. †† By the 2013 National Center for Health Statistics Urban-Rural Classification Scheme for Counties. https://www.cdc.gov/nchs/data_access/urban_rural.htm. §§ Northeast: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont. Midwest: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin. South: Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia. West: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming. ¶¶ Analyses were limited to states meeting the following criteria. States with very good to excellent reporting had ≥90% of drug overdose deaths mention at least one specific drug in 2017, with the change in drug overdose deaths mentioning of at least one specific drug differing by <10 percentage points from 2017 to 2018. States with good reporting had 80% to <90% of drug overdose deaths mention at least one specific drug in 2017, with the change in the percentage of drug overdose deaths mentioning at least one specific drug differing by <10 percentage points from 2017 to 2018. States included also were required to have stable rate estimates (i.e., based on ≥20 deaths in at least two of the following drug categories: opioids, prescription opioids, synthetic opioids other than methadone, and heroin). *** Absolute rate change is the difference between 2017 and 2018 rates. Relative rate change is the absolute rate change divided by the 2017 rate, multiplied by 100. Nonoverlapping confidence intervals based on the gamma method were used if the number of deaths was <100 in 2017 or 2018, and z-tests were used if the number of deaths was ≥100 in both 2017 and 2018. ††† Statistically significant (p-value <0.05). Prescription opioid-involved death rates decreased by 13.5% from 2017 to 2018. Rates decreased in males and females, persons aged 15–64 years, non-Hispanic whites, Hispanics, non-Hispanic American Indian/Alaska Natives, and across all urbanization levels. Prescription opioid–involved death rates remained stable in the Northeast and decreased in the Midwest, South, and the West. Seventeen states experienced declines in prescription opioid–involved death rates, with no states experiencing significant increases. The largest relative decrease occurred in Ohio (–40.5%), whereas the largest absolute decrease occurred in West Virginia (–4.1), which also had the highest prescription opioid-involved death rate in 2018 (13.1 per 100,000). Heroin-involved death rates decreased 4.1% from 2017 to 2018; reductions occurred among males and females, persons aged 15–34 years, non-Hispanic whites, and in large central metro and large fringe metro areas (Table 2). Rates decreased in the Midwest and increased in the West. Rates decreased in seven states and DC and increased in three states from 2017 to 2018. The largest relative decrease occurred in Kentucky (50.0%), and the largest absolute decrease occurred in DC (–7.1); the largest relative and absolute increase was in Tennessee (18.8%, 0.9). The highest heroin-involved death rate in 2018 was in Vermont (12.5 per 100,000). TABLE 2 Annual number and age-adjusted rate of drug overdose deaths* involving heroin † and synthetic opioids other than methadone, § , ¶ by sex, age, race/ethnicity,** urbanization level, †† U.S. Census region, §§ and selected states ¶¶ — National Vital Statistics System, United States, 2017 and 2018 Decedent characteristic Heroin Synthetic opioids other than methadone 2017 2018 Rate change from 2017 to 2018*** 2017 2018 Rate change from 2017 to 2018*** No. (rate) No. (rate) Absolute change Relative change No. (rate) No. (rate) Absolute change Relative change All 15,482 (4.9) 14,996 (4.7) −0.2††† −4.1††† 28,466 (9.0) 31,335 (9.9) 0.9††† 10.0††† Sex Male 11,596 (7.3) 11,291 (7.1) −0.2 ††† −2.7 ††† 20,524 (13.0) 22,528 (14.2) 1.2 ††† 9.2 ††† Female 3,886 (2.5) 3,705 (2.3) −0.2 ††† −8.0 ††† 7,942 (5.0) 8,807 (5.5) 0.5 ††† 10.0 ††† Age group (yrs) 0–14 —§§§ —§§§ —§§§ —§§§ 33 (0.1) 29 (0.1) 0.0 0.0 15–24 1,454 (3.4) 1,160 (2.7) −0.7 ††† −20.6 ††† 2,655 (6.1) 2,640 (6.1) 0.0 0.0 25–34 4,890 (10.8) 4,642 (10.2) −0.6 ††† −5.6 ††† 8,825 (19.5) 9,568 (20.9) 1.4 ††† 7.2 ††† 35–44 3,713 (9.1) 3,740 (9.1) 0.0 0.0 7,084 (17.3) 8,070 (19.6) 2.3 ††† 13.3 ††† 45–54 3,043 (7.2) 2,922 (7.0) −0.2 −2.8 5,762 (13.6) 6,132 (14.7) 1.1 ††† 8.1 ††† 55–64 2,005 (4.8) 2,077 (4.9) 0.1 2.1 3,481 (8.3) 4,018 (9.5) 1.2 ††† 14.5 ††† ≥65 368 (0.7) 445 (0.8) 0.1 14.3 620 (1.2) 871 (1.7) 0.5 ††† 41.7 ††† Sex and age group (yrs) Male 15–24 1,031 (4.7) 821 (3.7) −1.0 ††† −21.3 ††† 1,877 (8.5) 1,841 (8.4) −0.1 −1.2 Male 25–44 6,428 (14.8) 6,305 (14.4) −0.4 −2.7 11,693 (27.0) 12,810 (29.2) 2.2 ††† 8.1 ††† Male 45–64 3,830 (9.3) 3,778 (9.2) −0.1 −1.1 6,524 (15.8) 7,195 (17.6) 1.8 ††† 11.4 ††† Female 15–24 423 (2.0) 339 (1.6) −0.4 ††† −20.0 ††† 778 (3.7) 799 (3.8) 0.1 2.7 Female 25–44 2,175 (5.1) 2,077 (4.8) −0.3 −5.9 4,216 (9.8) 4,828 (11.2) 1.4 ††† 14.3 ††† Female 45–64 1,218 (2.8) 1,221 (2.8) 0.0 0.0 2,719 (6.3) 2,955 (6.9) 0.6 ††† 9.5 ††† Race/Ethnicity** White, non-Hispanic 11,293 (6.1) 10,756 (5.8) −0.3 ††† −4.9 ††† 21,956 (11.9) 23,214 (12.6) 0.7 ††† 5.9 ††† Black, non-Hispanic 2,140 (4.9) 2,145 (4.9) 0.0 0.0 3,832 (9.0) 4,780 (11.0) 2.0 ††† 22.2 ††† Hispanic 1,669 (2.9) 1,768 (3.1) 0.2 6.9 2,152 (3.7) 2,766 (4.7) 1.0 ††† 27.0 ††† American Indian/Alaska Native, non-Hispanic 136 (5.2) 133 (5.1) −0.1 −1.9 171 (6.5) 191 (7.3) 0.8 12.3 Asian/Pacific Islander, non-Hispanic 119 (0.5) 85 (0.4) −0.1 −20.0 189 (0.8) 214 (1.0) 0.2 ††† 25.0 ††† County urbanization level†† Large central metro 5,820 (5.6) 5,467 (5.2) −0.4 ††† −7.1 ††† 8,511 (8.2) 9,804 (9.4) 1.2 ††† 14.6 ††† Large fringe metro 4,526 (5.8) 4,321 (5.5) −0.3 ††† −5.2 ††† 8,991 (11.6) 9,871 (12.7) 1.1 ††† 9.5 ††† Medium metro 2,973 (4.6) 3,091 (4.8) 0.2 4.3 6,254 (9.8) 6,750 (10.5) 0.7 ††† 7.1 ††† Small metro 972 (3.6) 949 (3.5) −0.1 −2.8 1,878 (7.0) 2,050 (7.6) 0.6 ††† 8.6 ††† Micropolitan (nonmetro) 801 (3.3) 780 (3.3) 0.0 0.0 1,860 (7.7) 1,925 (8.0) 0.3 3.9 Noncore (nonmetro) 390 (2.4) 388 (2.4) 0.0 0.0 972 (6.0) 935 (5.8) −0.2 −3.3 U.S. Census region of residence§§ Northeast 4,310 (7.8) 4,363 (8.0) 0.2 2.6 8,861 (16.2) 10,351 (19.1) 2.9 ††† 17.9 ††† Midwest 4,228 (6.5) 3,575 (5.5) −1.0 ††† −15.4 ††† 8,234 (12.8) 8,348 (12.9) 0.1 0.8 South 4,776 (4.0) 4,718 (3.9) −0.1 −2.5 9,906 (8.3) 10,443 (8.6) 0.3 ††† 3.6 ††† West 2,168 (2.8) 2,340 (3.0) 0.2 ††† 7.1 ††† 1,465 (1.9) 2,193 (2.8) 0.9 ††† 47.4 ††† States with very good to excellent reporting (n = 29)¶¶ Alaska 36 (4.9) 29 (3.8) −1.1 −22.4 37 (4.9) 18 –§§§ –§§§ –§§§ Arizona 334 (5.0) 352 (5.2) 0.2 4.0 267 (4.0) 522 (7.7) 3.7 ††† 92.5 ††† Connecticut 425 (12.4) 338 (9.9) −2.5 ††† −20.2 ††† 686 (20.3) 767 (22.5) 2.2 10.8 District of Columbia 127 (18) 79 (10.9) −7.1 ††† −39.4 ††† 182 (25.7) 162 (22.6) −3.1 −12.1 Georgia 263 (2.6) 299 (2.9) 0.3 11.5 419 (4.1) 349 (3.4) −0.7 ††† −17.1 ††† Illinois 1,187 (9.2) 1,050 (8.3) −0.9 ††† −9.8 ††† 1,251 (9.8) 1,568 (12.4) 2.6 ††† 26.5 ††† Iowa 61 (2.1) 37 (1.3) −0.8 −38.1 92 (3.2) 80 (2.8) −0.4 −12.5 Maine 76 (6.2) 71 (6.0) −0.2 −3.2 278 (23.5) 229 (19.8) −3.7 −15.7 Maryland 522 (8.6) 356 (5.9) −2.7 ††† −31.4 ††† 1,542 (25.2) 1,825 (29.6) 4.4 ††† 17.5 ††† Massachusetts 466 (7.0) 475 (7.0) 0.0 0.0 1,649 (24.5) 1,806 (26.8) 2.3 ††† 9.4 ††† Missouri 299 (5.3) 351 (6.1) 0.8 15.1 618 (10.9) 868 (15.3) 4.4 ††† 40.4 ††† Nevada 94 (3.1) 108 (3.5) 0.4 12.9 66 (2.2) 85 (2.8) 0.6 27.3 New Hampshire 28 (2.4) 12 –§§§ –§§§ –§§§ 374 (30.4) 386 (31.3) 0.9 3.0 New Mexico 144 (7.4) 130 (6.6) −0.8 −10.8 75 (3.7) 105 (5.4) 1.7 45.9 New York 1,356 (6.8) 1,243 (6.3) −0.5 −7.4 2,238 (11.3) 2,195 (11.2) −0.1 −0.9 North Carolina 537 (5.6) 619 (6.3) 0.7 12.5 1,285 (13.2) 1,272 (13.0) −0.2 −1.5 Ohio 1,000 (9.2) 721 (6.6) −2.6 ††† −28.3 ††† 3,523 (32.4) 2,783 (25.7) −6.7 ††† −20.7 ††† Oklahoma 61 (1.6) 84 (2.2) 0.6 37.5 102 (2.6) 79 (2.0) −0.6 −23.1 Oregon 124 (3.0) 154 (3.7) 0.7 23.3 85 (2.1) 97 (2.4) 0.3 14.3 Rhode Island 14—§§§ 24 (2.2) –§§§ –§§§ 201 (20.1) 213 (21.0) 0.9 4.5 South Carolina 153 (3.2) 183 (3.8) 0.6 18.8 404 (8.5) 510 (10.8) 2.3 ††† 27.1 ††† Tennessee 311 (4.8) 369 (5.7) 0.9 ††† 18.8 ††† 590 (9.3) 827 (12.8) 3.5 ††† 37.6 ††† Utah 147 (4.8) 156 (5.1) 0.3 6.3 92 (3.1) 83 (2.9) −0.2 −6.5 Vermont 41 (7.3) 68 (12.5) 5.2 71.2 77 (13.8) 106 (19.3) 5.5 39.9 Virginia 556 (6.7) 532 (6.4) −0.3 −4.5 829 (10.0) 852 (10.3) 0.3 3.0 Washington 306 (4.0) 328 (4.2) 0.2 5.0 143 (1.9) 221 (2.9) 1.0 ††† 52.6 ††† West Virginia 244 (14.9) 195 (12.3) −2.6 −17.4 618 (37.4) 551 (34.0) −3.4 −9.1 Wisconsin 414 (7.8) 327 (6.0) −1.8 ††† −23.1 ††† 466 (8.6) 506 (9.4) 0.8 9.3 Wyoming —§§§ —§§§ —§§§ —§§§ —§§§ —§§§ —§§§ —§§§ States with good reporting (n = 10)¶¶ California 715 (1.7) 778 (1.9) 0.2 ††† 11.8 ††† 536 (1.3) 865 (2.2) 0.9 ††† 69.2 ††† Colorado 224 (3.9) 233 (3.9) 0.0 0.0 112 (2.0) 134 (2.2) 0.2 10.0 Florida 707 (3.6) 689 (3.5) −0.1 −2.8 2,126 (11.0) 2,091 (10.7) −0.3 −2.7 Hawaii 10 —§§§ —§§§ —§§§ —§§§ —§§§ —§§§ —§§§ —§§§ Indiana 327 (5.3) 311 (5.0) −0.3 −5.7 649 (10.5) 713 (11.5) 1.0 9.5 Kentucky 269 (6.6) 140 (3.3) −3.3 ††† −50.0 ††† 780 (19.1) 744 (17.9) −1.2 −6.3 Michigan 783 (8.2) 633 (6.5) −1.7 ††† −20.7 ††† 1,368 (14.4) 1,531 (16.0) 1.6 ††† 11.1 ††† Minnesota 111 (2.0) 93 (1.7) −0.3 −15.0 184 (3.5) 202 (3.7) 0.2 5.7 Mississippi 34 (1.3) 39 (1.4) 0.1 7.7 81 (2.9) 72 (2.6) −0.3 −10.3 Texas 569 (2.0) 668 (2.3) 0.3 ††† 15.0 ††† 348 (1.2) 358 (1.2) 0.0 0.0 * Deaths were classified using the International Classification of Diseases, Tenth Revision (ICD–10). Drug overdose deaths were identified using underlying cause-of-death codes X40–X44, X60–X64, X85, and Y10–Y14. Rates are age-adjusted using the direct method and the 2000 U.S. standard population, except for age-specific crude rates. All rates were per 100,000 population. † Drug overdose deaths, as defined, that have heroin (T40.1) as a contributing cause. § Drug overdose deaths, as defined, that have semisynthetic opioids other than methadone (T40.4) as a contributing cause. ¶ Categories of deaths are not exclusive as deaths might involve more than one drug category. Summing of categories will result in more than the total number of deaths in a year. ** Data on Hispanic origin should be interpreted with caution; studies comparing Hispanic origin on death certificates and on Census surveys have shown inconsistent reporting on Hispanic ethnicity. Potential race misclassification might lead to underestimates for certain categories, primarily American Indian/Alaska Native non-Hispanic and Asian/Pacific Islander non-Hispanic decedents. https://www.cdc.gov/nchs/data/series/sr_02/sr02_172.pdf. †† By the 2013 National Center for Health Statistics Urban-Rural Classification Scheme for Counties. https://www.cdc.gov/nchs/data_access/urban_rural.htm. §§ Northeast: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont. Midwest: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin. South: Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia. West: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming. ¶¶ Analyses were limited to states meeting the following criteria. States with very good to excellent reporting had ≥90% of drug overdose deaths mention at least one specific drug in 2017, with the change in drug overdose deaths mentioning of at least one specific drug differing by <10 percentage points from 2017 to 2018. States with good reporting had 80% to <90% of drug overdose deaths mention at least one specific drug in 2017, with the change in the percentage of drug overdose deaths mentioning at least one specific drug differing by <10 percentage points from 2017 to 2018. States included also were required to have stable rate estimates (i.e., based on ≥20 deaths in at least two of the following drug categories: opioids, prescription opioids, synthetic opioids other than methadone, and heroin). *** Absolute rate change is the difference between 2017 and 2018 rates. Relative rate change is the absolute rate change divided by the 2017 rate, multiplied by 100. Nonoverlapping confidence intervals based on the gamma method were used if the number of deaths was <100 in 2017 or 2018, and z-tests were used if the number of deaths was ≥100 in both 2017 and 2018. ††† Statistically significant (p-value <0.05). §§§ Cells with nine or fewer deaths are not reported. Rates based on <20 deaths are not considered stable rate estimates and are not reported. Death rates involving synthetic opioids increased from 9.0 per 100,000 population in 2017 to 9.9 in 2018 and accounted for 67.0% of opioid-involved deaths in 2018. These rates increased from 2017 to 2018 among males and females, persons aged ≥25 years, non-Hispanic whites, non-Hispanic blacks, Hispanics, non-Hispanic Asian/Pacific Islanders, and in large central metro, large fringe metro, medium metro, and small metro counties. Synthetic opioid–involved death rates increased in the Northeast, South and West and remained stable in the Midwest. Rates increased in 10 states and decreased in two states. The largest relative increase occurred in Arizona (92.5%), and the largest absolute increase occurred in Maryland and Missouri (4.4 per 100,000 in both states); the largest relative and absolute decrease was in Ohio (–20.7%, –6.7). The highest synthetic opioid–involved death rate in 2018 occurred in West Virginia (34.0 per 100,000). Discussion During 1999–2018, opioids were involved in 446,032 deaths in the United States. §§§ From 2017 to 2018, relative decreases occurred in death rates involving all drug overdoses (–4.1%), all opioids (–2.0%), prescription opioids (–13.5%), and heroin (–4.1%); a relative increase occurred in the rate of overdose deaths involving synthetic opioids (10.0%). Decreases in all opioid-involved death rates were largely driven by those involving prescription opioids. The number of filled opioid prescriptions peaked in 2012 and decreased thereafter ( 4 ). Efforts to reduce high-dose opioid prescribing ¶¶¶ ( 4 ) have increased and have contributed to decreases in prescription opioid–involved deaths. Factors that might be contributing to the decrease in heroin-involved deaths include fewer persons initiating heroin use ( 5 ), shifts from a heroin-based market to a fentanyl-based market ( 6 ), increased treatment provision for persons using heroin, and expansion of naloxone access ( 5 , 7 ). Increases in synthetic opioid–involved deaths are likely driven by proliferation of IMF or fentanyl analogs in the illicit drug supply ( 3 , 5 , 6 ). According to the Drug Enforcement Administration, fentanyl was the most identified synthetic opioid found during drug seizures in the first half of 2017 ( 6 ); in addition, fentanyl reports in all regions increased during 2014–2018.**** This is consistent with current findings indicating recent increases in synthetic opioid–involved death rates in all regions except the Midwest. The findings in this report are subject to at least five limitations. First, postmortem toxicology testing varies by jurisdiction; improvements in testing might account for some reported increases. Second, the percentage of 2017 and 2018 death certificates with at least one drug specified varied among states and over time, limiting opioid subcategory rate comparisons. Third, because heroin is metabolized to morphine ( 8 ), some heroin deaths might have been misclassified as morphine deaths, resulting in an underreporting of heroin deaths. Fourth, potential race misclassification might have led to underestimates for certain categories, particularly American Indian/Alaska Natives and Asian/Pacific Islanders. †††† Finally, adequate drug specificity data were available from only 38 states and DC, which might limit generalizability of state-based analyses. From 2017 to 2018, small decreases occurred in all overdose deaths and in deaths involving all opioids, prescription opioids, and heroin; however, deaths involving synthetic opioids continued to increase in 2018 and accounted for two thirds of opioid-involved deaths. Findings also highlight increases in deaths among non-Hispanic blacks and Hispanics, indicating the need for culturally tailored interventions that address social determinants of health and structural-level factors. In addition, changing substance use patterns, including the resurgence of methamphetamine use, particularly among persons using opioids ( 9 ) and the mixing of opioids with methamphetamine and cocaine in the illicit drug supply ( 6 ), have continued to make the drug overdose landscape more complicated and surveillance and prevention efforts more challenging. To sustain decreases and prevent continued increases, continued urgent action is needed. Overdose Data to Action §§§§ is a 3-year cooperative agreement through which CDC funds health departments in 47 states, DC, two territories, and 16 cities and counties for surveillance and prevention efforts. These measures include obtaining more timely data on all drug overdoses, improving toxicology to better identify polysubstance-involved deaths, enhancing linkage to treatment for persons with opioid use disorder and risk for opioid overdose, improving prescription drug monitoring programs, implementing health systems interventions, partnering with public safety, and implementing other innovative surveillance and prevention activities. Because of the reductions observed in deaths involving prescription opioids, continued efforts to encourage safe prescribing practices, such as following the CDC Guideline for Prescribing Opioids for Chronic Pain ( 10 ) might be enhanced by increased use of nonopioid and nonpharmacologic treatments for pain. Additional public health efforts to reduce opioid-involved overdose deaths include expanding the distribution of naloxone, addressing polysubstance use, and increasing the provision of medication-assisted treatment. Enhanced and coordinated multisectoral surveillance of the illicit drug supply ¶¶¶¶ to track emerging threats, including the type and amount of specific drugs, could also help prevent overdoses. A comprehensive, multisectoral surveillance, prevention, and response approach remains critical for sustaining and expanding preliminary successes in reducing opioid-involved overdose deaths and specifically curtailing synthetic opioid–involved deaths and other emerging threats. Summary What is already known about this topic? In 2017, 68% of the 70,237 U.S. drug overdose deaths involved an opioid. During 2016–2017, deaths involving all opioids and synthetic opioids increased; deaths involving prescription opioids and heroin remained stable. What is added by this report? Opioids were involved in approximately 70% (46,802) of drug overdose deaths during 2018, representing decreases from 2017 in overdose death rates involving all opioids (2% decline), prescription opioids (14%), and heroin (4%); rates involving synthetic opioids increased 10%. What are the implications for public health practice? Surveillance of overdose and polysubstance use trends and the illicit drug supply to track emerging threats, enhancing linkage to treatment, and a multisectoral response are critical to sustaining and accelerating declines in opioid-involved deaths.
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              Trends and Geographic Patterns in Drug and Synthetic Opioid Overdose Deaths — United States, 2013–2019

              Deaths involving synthetic opioids other than methadone (synthetic opioids), which largely consist of illicitly manufactured fentanyl; psychostimulants with abuse potential (e.g., methamphetamine); and cocaine have increased in recent years, particularly since 2013 ( 1 , 2 ). In 2019, a total of 70,630 drug overdose deaths occurred, corresponding to an age-adjusted rate of 21.6 per 100,000 population and a 4.3% increase from the 2018 rate (20.7) ( 3 ). CDC analyzed trends in age-adjusted overdose death rates involving synthetic opioids, psychostimulants, cocaine, heroin, and prescription opioids during 2013–2019, as well as geographic patterns in synthetic opioid- and psychostimulant-involved deaths during 2018–2019. From 2013 to 2019, the synthetic opioid-involved death rate increased 1,040%, from 1.0 to 11.4 per 100,000 age-adjusted (3,105 to 36,359). The psychostimulant-involved death rate increased 317%, from 1.2 (3,627) in 2013 to 5.0 (16,167) in 2019. In the presence of synthetic opioid coinvolvement, death rates for prescription opioids, heroin, psychostimulants, and cocaine increased. In the absence of synthetic opioid coinvolvement, death rates increased only for psychostimulants and cocaine. From 2018 to 2019, the largest relative increase in the synthetic opioid-involved death rate occurred in the West (67.9%), and the largest relative increase in the psychostimulant-involved death rate occurred in the Northeast (43.8%); these increases represent important changes in the geographic distribution of drug overdose deaths. Evidence-based prevention and response strategies including substance use disorder treatment and overdose prevention and response efforts focused on polysubstance use must be adapted to address the evolving drug overdose epidemic. Drug overdose deaths were identified in the National Vital Statistics System multiple cause-of-death mortality files* by using International Classification of Diseases, Tenth Revision (ICD-10) underlying cause-of-death codes X40–44 (unintentional), X60–64 (suicide), X85 (homicide), or Y10–14 (undetermined intent). Drug categories were defined using the following ICD-10 multiple cause-of-death codes: synthetic opioids other than methadone (T40.4), psychostimulants with abuse potential (T43.6), cocaine (T40.5), prescription opioids (T40.2 or T40.3), and heroin (T40.1). Deaths involving more than one type of drug were included in the rates for each applicable drug category; categories are not mutually exclusive. † Annual age-adjusted death rates § were examined during 2013–2019 and stratified by drug category and synthetic opioid coinvolvement. The percentage of 2019 drug overdose deaths and change in 2018–2019 age-adjusted death rates involving synthetic opioids and psychostimulants were examined by U.S Census region ¶ and state. States with inadequate drug specificity, too few deaths to calculate stable estimates, or too few deaths to meet confidentiality requirements were excluded from state-level analyses.** ,†† Analyses of rate changes used z-tests when deaths were ≥100 and nonoverlapping confidence intervals based on a gamma distribution when deaths were 80% of drug overdose death certificates named at least one specific drug in 2019 and ≥10 deaths occurred in 2019 in the specific drug category. † Rate per 100,000 population age-adjusted to the 2000 U.S. standard population using the vintage year population of the data year. § Z-tests were used if the number of deaths was ≥100 in both 2018 and 2019, and p 80% of drug overdose death certificates named at least one specific drug in 2018 and 2019 and ≥20 deaths occurred during 2018 and 2019 in the drug category examined. †† Deaths were classified using the International Classification of Diseases, Tenth Revision. Drug overdoses are identified using underlying cause-of-death codes X40–X44 (unintentional), X60–X64 (suicide), X85 (homicide), and Y10–Y14 (undetermined). §§ Drug overdose deaths, as defined, that involve synthetic opioids other than methadone (T40.4). ¶¶ Drug overdose deaths, as defined, that involve psychostimulants with abuse potential (T43.6). *** Because deaths might involve more than one drug, some deaths are included in more than one category. In 2019, 6.3% of drug overdose deaths did not include information on the specific type of drug(s) involved. The figure is a series of maps showing percent and relative change in age-adjusted rates of drug overdose deaths involving synthetic opioids other than methadone and psychostimulants with abuse potential in the United States during 2013–2019. From 2018 to 2019, the age-adjusted synthetic opioid-involved death rate increased 15.2%, from 9.9 to 11.4. In 2019, the Northeast had the highest percentage and rate of deaths involving synthetic opioids, but the smallest relative (5.2%) and absolute (1.0) rate increases from the previous year (19.1 in 2018 to 20.1 in 2019). In contrast, the West experienced the largest relative (67.9%) and absolute (1.9) rate increases from 2.8 in 2018 to 4.7 in 2019. From 2018 to 2019, a total of 20 states experienced relative increases in their synthetic opioid-involved death rate, with the highest rate in 2019 in Delaware (38.4). The largest relative rate increase occurred in Colorado (95.5%), and the largest absolute rate increase occurred in the District of Columbia (7.6). No state experienced a significant decrease. The percentage of deaths involving psychostimulants was highest in the West (43.5%) and lowest in the Northeast (7.9%) in 2019. The same geographic pattern was observed with psychostimulant-involved deaths that did not coinvolve synthetic opioids. In all northeastern states, fewer than 20% of drug overdose deaths involved psychostimulants. In 12 states, mostly in the West and Midwest, ≥40% of overdose deaths involved psychostimulants. Among these, the percentage was highest in Hawaii (70.2%) and Oklahoma (50.7%). The percentage was lowest in Maryland (3.3%). From 2018 to 2019, the age-adjusted rate of psychostimulant-involved deaths increased 28.2%, from 3.9 to 5.0. The Northeast experienced the largest relative (43.8%), but smallest absolute (0.7), rate increase. The Midwest (36.1%) and South (32.4%) experienced similar relative but slightly larger absolute (1.3 and 1.2, respectively) rate increases. Although the percentage of 2019 drug overdose deaths involving psychostimulants was highest in the West, the relative rate increase (17.5%) was lowest there. Twenty-four states experienced an increase in the rate of psychostimulant-involved deaths. Kansas experienced the largest relative increase (107.1%) and third largest absolute rate increase (3.0). West Virginia had the highest 2019 rate (24.4) and the largest absolute rate increase (5.1); New York had the lowest 2019 rate (1.3). No state had a significant decrease (Supplementary Table, https://stacks.cdc.gov/view/cdc/101757). Discussion In 2019, a total of 70,630 drug overdose deaths occurred in the United States; approximately one half involved synthetic opioids. From 2013 to 2019, the age-adjusted synthetic opioid death rate increased sharply by 1,040%, from 1.0 to 11.4. Death rates involving prescription opioids and heroin increased in the presence of synthetic opioids (from 0.3 to 1.8 and from 0.1 to 2.7, respectively), but not in their absence. Death rates involving psychostimulants increased 317% overall, regardless of synthetic opioid coinvolvement. Synthetic opioid- and psychostimulant-involved deaths shifted geographically from 2018 to 2019. From 2015 to 2016, states in the East had the largest increases in deaths involving synthetic opioids, and from 2016 to 2017, the Midwest had the largest increases in deaths involving psychostimulants ( 2 , 4 ). In contrast, from 2018 to 2019, the largest relative increase in death rates involving synthetic opioids occurred in the West (67.9%); the largest relative increase in death rate involving psychostimulants occurred in the Northeast (43.8%). Sharp increases in synthetic opioid- and psychostimulant-involved overdose deaths in 2019 are consistent with recent trends indicating a worsening and expanding drug overdose epidemic ( 1 , 2 , 4 – 6 ). Synthetic opioids, particularly illicitly manufactured fentanyl and fentanyl analogs, are highly potent, increasingly available across the United States, and found in the supplies of other drugs ( 7 , 8 ). Co-use of synthetic opioids with other drugs can be deliberate or inadvertent (i.e., products might be adulterated with illicitly manufactured fentanyl or fentanyl analogs unbeknownst to the user). Similarly, psychostimulant-involved deaths are likely rising because of increases in potency, availability, and reduced cost of methamphetamine in recent years ( 9 ). The increase in synthetic-opioid involved deaths in the West and in psychostimulant-involved deaths in the Northeast signal broadened geographic use of these substances, consistent with increases in the number of drug submissions to forensic laboratories in those regions during 2018–2019 ( 8 ). The findings in this report are subject to at least two limitations. First, forensic toxicology testing protocols varied by time and jurisdiction, particularly for synthetic opioids. Therefore, some of the increases in overdose deaths reported by drug categories could be attributed to the increases in testing as well as the use of more comprehensive tests. Second, geographic analyses excluded states with inadequate drug specificity or too few deaths to calculate stable rates. The worsening and expanding drug overdose epidemic in the United States now involves potent synthetic drugs, often in combination with other substances, and requires urgent action. As involved substances and geographic trends in drug overdose deaths change, timely surveillance and evidence-based prevention and response strategies remain essential. CDC’s Overdose Data to Action ¶¶ cooperative agreement funds health departments in 47 states, the District of Columbia, two territories, and 16 cities and counties to obtain high-quality, comprehensive, and timely data on fatal and nonfatal drug overdoses to inform prevention and response efforts. To help curb this epidemic, Overdose Data to Action strategies focus on enhancing linkage to and retention in substance use disorder treatment, improving prescription drug monitoring programs, implementing postoverdose protocols in emergency departments, including naloxone provision to patients who use opioids or other illicit drugs, and strengthening public health and public safety partnerships, enabling data sharing to help inform comprehensive interventions.*** Other approaches ††† should include expanded naloxone distribution and education that potent opioids might require multiple doses of naloxone, improved access to substance use disorder treatment (including medications for opioid use disorder or programs addressing polysubstance use), expanded harm reduction services, and continued partnerships with public safety to monitor trends in the illicit drug supply, including educating the public that drug products might be adulterated with fentanyl or fentanyl analogs unbeknownst to users. A comprehensive and coordinated approach from clinicians, public health, public safety, community organizations, and the public must incorporate innovative and established prevention and response strategies, including those focused on polysubstance use. Summary What is already known about this topic? Deaths involving synthetic opioids other than methadone, cocaine, and psychostimulants have increased in recent years. What is added by this report? From 2013 to 2019, the age-adjusted rate of deaths involving synthetic opioids other than methadone increased 1,040%, and for psychostimulants increased 317%. During 2018–2019, the largest relative increase in synthetic opioid-involved death rates occurred in the West (67.9%), and the largest relative increase in psychostimulant-involved death rates occurred in the Northeast (43.8%). What are the implications for public health practice? Evidence-based prevention and response strategies, including substance use disorder treatment and overdose prevention and response efforts focused on polysubstance use, must be adapted to address the changing drug overdose epidemic.
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                Author and article information

                Journal
                BMJ Open
                BMJ Open
                bmjopen
                bmjopen
                BMJ Open
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2044-6055
                2022
                8 April 2022
                : 12
                : 5
                : e053686
                Affiliations
                [1 ] departmentParkinson School of Health Sciences and Public Health , Loyola University Chicago , Chicago, Illinois, USA
                [2 ] departmentDepartment of Family Medicine and Public Health Sciences , Wayne State University , Detroit, Michigan, USA
                [3 ] departmentDepartment of Family and Preventive Medicine , University of Utah Health , Salt Lake City, Utah, USA
                [4 ] departmentDepartment of Psychology , University of New Mexico , Albuquerque, New Mexico, USA
                [5 ] departmentAlbuquerque Area Southwest Tribal Epidemiology Center (AASTEC) , Albuquerque Area Indian Health Service , Albuquerque, New Mexico, USA
                Author notes
                [Correspondence to ] Dr Fares Qeadan; fqeadan@ 123456luc.edu
                Author information
                http://orcid.org/0000-0002-3376-220X
                http://orcid.org/0000-0003-0620-0858
                http://orcid.org/0000-0002-7161-8970
                Article
                bmjopen-2021-053686
                10.1136/bmjopen-2021-053686
                9109082
                35501103
                b7d4aab9-8c3f-4ba8-941e-09c9aeda395f
                © Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

                This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/.

                History
                : 09 June 2021
                : 04 March 2022
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/100000002, National Institutes of Health;
                Award ID: 5R61DA049382-02
                Categories
                Addiction
                1506
                1681
                Original research
                Custom metadata
                unlocked

                Medicine
                epidemiology,substance misuse,public health
                Medicine
                epidemiology, substance misuse, public health

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