Trends and Geographic Patterns in Drug and Synthetic Opioid Overdose Deaths — United States, 2013–2019

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Abstract

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 <100. §§ Changes presented in text represent statistically significant (p<0.05) findings unless otherwise specified. Statistical analyses were conducted in SAS (version 9.4; SAS Institute) and maps were created using QGIS (version 3.4.11-Madeira; QGIS Association). In 2019, a total of 70,630 drug overdose deaths occurred in the United States, corresponding to an age-adjusted rate of 21.6 per 100,000 population and a 56.5% increase above the 2013 rate of 13.8. 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) (Figure 1). The psychostimulant-involved death rate increased 317%, from 1.2 (3,627) in 2013 to 5.0 (16,167) in 2019. Smaller but meaningful increases were observed during this period for cocaine (206%; 1.6 to 4.9) and heroin (63%; 2.7 to 4.4). The prescription opioid-involved death rate decreased 4.5% from 4.4 in 2013 to 4.2 in 2019. FIGURE 1 Age-adjusted rates* of drug overdose deaths † involving prescription opioids, § heroin, ¶ cocaine,** psychostimulants with abuse potential, †† and synthetic opioids other than methadone §§ , ¶¶ — United States, 2013–2019 Source: National Vital Statistics System, Mortality File. https://wonder.cdc.gov/ * Rate per 100,000 population age-adjusted to the 2000 U.S. standard population using the vintage year population of the data year. † 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 natural and semisynthetic opioids (T40.2) or methadone (T40.3). ¶ Drug overdose deaths, as defined, that involve heroin (T40.1). ** Drug overdose deaths, as defined, that involve cocaine (T40.5). †† Drug overdose deaths, as defined, that involve psychostimulants with abuse potential (T43.6). §§ Drug overdose deaths, as defined, that involve synthetic opioids other than methadone (T40.4). ¶¶ 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 line graph showing age-adjusted rates of drug overdose deaths involving prescription opioids, heroin, cocaine, psychostimulants with abuse potential, and synthetic opioids other than methadone, by year, in the United States from 2013–2019. In the presence of synthetic opioid coinvolvement, age-adjusted death rates for all drug categories increased from 2013 to 2019: psychostimulants (0.1 to 1.8), cocaine (0.1 to 3.2), heroin (0.1 to 2.7) and prescription opioids (0.3 to 1.8) (Figure 2). In the absence of synthetic opioid coinvolvement, the age-adjusted death rate increased from 2013 to 2019 for psychostimulants (1.1 to 3.2) and cocaine (1.5 to 1.7); however, rates decreased for prescription opioid- (4.1 to 2.4) and heroin-involved deaths (2.6 to 1.6). FIGURE 2 Age-adjusted rates* of drug overdose deaths † involving prescription opioids, § heroin, ¶ cocaine,** and psychostimulants with abuse potential, †† with (A) and without (B) synthetic opioids other than methadone §§ , ¶¶ — United States, 2013–2019 Source: National Vital Statistics System, Mortality File. https://wonder.cdc.gov/ * Rate per 100,000 population age-adjusted to the 2000 U.S. standard population using the vintage year population of the data year. † 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 natural and semisynthetic opioids (T40.2) or methadone (T40.3). ¶ Drug overdose deaths, as defined, that involve heroin (T40.1). ** Drug overdose deaths, as defined, that involve cocaine (T40.5). †† Drug overdose deaths, as defined, that involve psychostimulants with abuse potential (T43.6). §§ Drug overdose deaths, as defined, that involve synthetic opioids other than methadone (T40.4). ¶¶ 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 pair of line graphs showing age-adjusted rates of drug overdose deaths involving prescription opioids, heroin, cocaine, and psychostimulants with abuse potential, with and without synthetic opioids other than methadone, by year, in the United States during 2013–2019. In 2019, a total of 49,860 (70.6%) drug overdose deaths involved opioids, 36,359 (51.5%) involved synthetic opioids, and 16,167 (22.9%) involved psychostimulants. The percentage of drug overdose deaths that involved synthetic opioids was highest in the Northeast (71.0%) and lowest in the West (26.4%). In nine states, ≥70% of overdose deaths involved synthetic opioids (Figure 3); the percentage was highest in New Hampshire (84.3%). FIGURE 3 Percentage* and relative change in age-adjusted rates † , § , ¶ , ** of drug overdose deaths †† involving synthetic opioids other than methadone (A, B) §§ and psychostimulants with abuse potential (C, D) ¶¶ ,*** — United States, 2018–2019 Source: National Vital Statistics System, Mortality File. https://wonder.cdc.gov/ Abbreviation: DC = District of Columbia. *State-level analyses of the percentage of drug overdose deaths involving synthetic opioids excluded one state and involving psychostimulants excluded two states that did not meet the following criteria: >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<0.05 was statistically significant. Nonoverlapping confidence intervals (CIs) based on the gamma method were used if the number of deaths was <100 in 2018 or 2019. The method of comparing CIs is a conservative method for statistical significance; caution should be observed when interpreting a nonsignificant difference when the lower and upper limits being compared overlap only slightly. https://www.cdc.gov/nchs/data/NVSR/NVSR61/NVSR61_04.pdf ¶ States with a statistically significant change in age-adjusted rate of drug overdose deaths involving synthetic opioids other than methadone during 2018–2019 were Arizona, California, Colorado, Connecticut, District of Columbia, Florida, Georgia, Illinois, Indiana, Kentucky, Minnesota, Mississippi, New Mexico, New York, Ohio, Tennessee, Texas, Virginia, Washington, and Wisconsin. States with a statistically significant change in age-adjusted rate of drug overdose deaths involving psychostimulants with abuse potential during 2018–2019 were Arizona, California, Florida, Indiana, Iowa, Kansas, Kentucky, Maine, Michigan, Minnesota, Missouri, New Jersey, New Mexico, New York, North Carolina, Ohio, Oregon, South Carolina, Tennessee, Texas, Virginia, Washington, West Virginia, and Wisconsin. ** State-level analyses comparing death rates from 2018 to 2019 excluded nine states that did not meet the following criteria: >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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Drug and Opioid-Involved Overdose Deaths — United States, 2017–2018

Nana O. Wilson, Mbabazi Kariisa, Puja Seth … (2020)

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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Drug Overdose Deaths Involving Cocaine and Psychostimulants with Abuse Potential — United States, 2003–2017

Mbabazi Kariisa, Lawrence E. Scholl, Nana O. Wilson … (2019)

In 2016, a total of 63,632 persons died from drug overdoses in the United States ( 1 ). Drug overdose deaths involving cocaine, psychostimulants with abuse potential (psychostimulants), or both substances combined increased 42.4% from 12,122 in 2015 to 17,258 in 2016.* Psychostimulants with abuse potential include drugs such as methamphetamine, 3,4-methylenedioxy-methamphetamine (MDMA), dextroamphetamine, levoamphetamine, methylphenidate (Ritalin), and caffeine. From 2015 to 2016, cocaine-involved and psychostimulant-involved death rates increased 52.4% and 33.3%, respectively ( 1 ). A total of 70,237 persons died from drug overdoses in the United States in 2017; approximately two thirds of these deaths involved an opioid ( 2 ). CDC analyzed 2016–2017 changes in age-adjusted death rates involving cocaine and psychostimulants by demographic characteristics, urbanization levels, U.S. Census region, 34 states, and the District of Columbia (DC). CDC also examined trends in age-adjusted cocaine-involved and psychostimulant-involved death rates from 2003 to 2017 overall, as well as with and without co-involvement of opioids. Among all 2017 drug overdose deaths, 13,942 (19.8%) involved cocaine, and 10,333 (14.7%) involved psychostimulants. Death rates increased from 2016 to 2017 for both drug categories across demographic characteristics, urbanization levels, Census regions, and states. In 2017, opioids were involved in 72.7% and 50.4% of cocaine-involved and psychostimulant-involved overdoses, respectively, and the data suggest that increases in cocaine-involved overdose deaths from 2012 to 2017 were driven primarily by synthetic opioids. Conversely, increases in psychostimulant-involved deaths from 2010 to 2017 occurred largely independent of opioids, with increased co-involvement of synthetic opioids in recent years. Provisional data from 2018 indicate that deaths involving cocaine and psychostimulants are continuing to increase. † Increases in stimulant-involved deaths are part of a growing polysubstance landscape. Increased surveillance and evidence-based multisectoral prevention and response strategies are needed to address deaths involving cocaine and psychostimulants and opioids. Enhancing linkage to care, building state and local capacity, and public health/public safety collaborations are critical components of prevention efforts. Drug overdose deaths were identified in the National Vital Statistics System multiple cause-of-death mortality files, § using 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 type of drug is indicated by the following ICD-10 multiple cause-of-death codes: cocaine (T40.5); psychostimulants with abuse potential (T43.6); opioids (T40.0–T40.4, and T40.6) ¶ ; and synthetic opioids other than methadone (T40.4). Some deaths involved more than one type of drug; these deaths were included in the rates for each drug category. Thus, categories were not mutually exclusive.** Age-adjusted death rates †† were examined for the period 2016– 2017 for cocaine and psychostimulants. Death rates were stratified by age group, sex, race/ethnicity, urbanization level, §§ U.S. Census region, ¶¶ and state. State-level analyses were conducted for 34 states and DC, all of which had adequate drug-specificity data recorded on death certificates for 2016 and 2017.*** Analyses comparing changes in death rates from 2016 to 2017 used z-tests when deaths were ≥100 and nonoverlapping confidence intervals based on a gamma distribution when deaths were <100. ††† Trends in age-adjusted cocaine-involved and psychostimulant-involved death rates from 2003 to 2017 were analyzed overall, and with and without any opioids and synthetic opioids, using Joinpoint regression. §§§ Changes presented represent statistically significant findings unless otherwise specified. In 2017, among 70,237 drug overdose deaths that occurred in the United States, 13,942 (19.8%) involved cocaine, representing a 34.4% increase from 2016 (Table). Nearly three fourths (72.7%) of cocaine-involved deaths in 2017 also involved opioids. Cocaine-involved death rates increased among both sexes and among persons aged ≥15 years, non-Hispanic whites (whites), non-Hispanic blacks (blacks), and Hispanics. The largest relative rate change occurred among females aged 15–24 years (40.0%), and the largest absolute rate change was among males aged 25–44 and 45–64 years (increase of 2.7 per 100,000). Among racial/ethnic groups, the highest rate of cocaine-involved deaths in 2017 occurred in blacks (8.3 per 100,000), who also experienced the largest relative rate change (36.1%) compared with 2016. By urban-rural status, counties in medium metro areas experienced the largest absolute rate increase (1.3 per 100,000) in 2017, whereas the largest relative rate increase occurred in micropolitan counties (57.9%). The Midwest Census region had the largest relative rate increase (43.6%), whereas the highest 2017 rate was in the Northeast (7.0 per 100,000). Death rates involving cocaine increased in 15 states, with the largest relative increases in Wisconsin (84.6%) and Maryland (72.0%), and the largest absolute rate increases in Ohio (3.9) and Maryland (3.6). In 2017, the highest death rates were in DC (17.6) and Ohio (14.0). TABLE Number and age-adjusted rate of drug overdose deaths* involving cocaine † and psychostimulants with abuse potential, § , ¶ by opioid involvement,** sex, age group, race and Hispanic origin, †† U.S. Census region, urbanization level, §§ and selected states ¶¶ — United States, 2016 and 2017 Decedent characteristic Involving cocaine Involving psychostimulants with abuse potential 2016 2017 Change from 2016 to 2017*** 2016 2017 Change from 2016 to 2017*** No. (Rate) No. (Rate) Absolute rate change % Change in rate No. (Rate) No. (Rate) Absolute rate change % Change in rate Overall 10,375 (3.2) 13,942 (4.3) 1.1††† 34.4††† 7,542 (2.4) 10,333 (3.2) 0.8††† 33.3††† With any opioid** 7,263 (2.3) 10,131 (3.2) 0.9††† 39.1††† 3,416 (1.1) 5,203 (1.7) 0.6††† 54.5††† Sex Male 7,493 (4.7) 10,021 (6.2) 1.5††† 31.9††† 5,348 (3.4) 7,240 (4.5) 1.1††† 32.4††† Female 2,882 (1.8) 3,921 (2.5) 0.7††† 38.9††† 2,194 (1.4) 3,093 (1.9) 0.5††† 35.7††† Age group (yrs) 0–14 §§§ §§§ §§§ §§§ 11§§§ §§§ §§§ §§§ 15–24 757 (1.7) 924 (2.1) 0.4††† 23.5††† 571 (1.3) 780 (1.8) 0.5††† 38.5††† 25–34 2,525 (5.7) 3,463 (7.6) 1.9††† 33.3††† 1,762 (3.9) 2,593 (5.7) 1.8††† 46.2††† 35–44 2,431 (6.0) 3,282 (8.0) 2.0††† 33.3††† 1,831 (4.5) 2,548 (6.2) 1.7††† 37.8††† 45–54 2,629 (6.1) 3,497 (8.3) 2.2††† 36.1††† 1,914 (4.5) 2,477 (5.8) 1.3††† 28.9††† 55–64 1,721 (4.2) 2,335 (5.6) 1.4††† 33.3††† 1,244 (3.0) 1,648 (3.9) 0.9††† 30.0††† ≥65 303 (0.6) 432 (0.8) 0.2††† 33.3††† 206 (0.4) 278 (0.5) 0.1††† 25.0††† Sex/Age group (yrs) Male 15–24 553 (2.5) 633 (2.9) 0.4††† 16.0††† 388 (1.7) 499 (2.3) 0.6††† 35.3††† 25–44 3,569 (8.3) 4,784 (11.0) 2.7††† 32.5††† 2,536 (5.9) 3,551 (8.2) 2.3††† 39.0††† 45–64 3,108 (7.6) 4,229 (10.3) 2.7††† 35.5††† 2,251 (5.5) 2,955 (7.2) 1.7††† 30.9††† Female 15–24 204 (1.0) 291 (1.4) 0.4††† 40.0††† 183 (0.9) 281 (1.3) 0.4††† 44.4††† 25–44 1,387 (3.3) 1,961 (4.6) 1.3††† 39.4††† 1,057 (2.5) 1,590 (3.7) 1.2††† 48.0††† 45–64 1,242 (2.9) 1,603 (3.7) 0.8††† 27.6††† 907 (2.1) 1,170 (2.7) 0.6††† 28.6††† Race and Hispanic origin†† White, non-Hispanic 6,443 (3.4) 8,614 (4.6) 1.2††† 35.3††† 5,777 (3.0) 7,995 (4.2) 1.2††† 40.0††† Black, non-Hispanic 2,599 (6.1) 3,554 (8.3) 2.2††† 36.1††† 477 (1.2) 663 (1.6) 0.4††† 33.3††† Hispanic 1,097 (2.0) 1,438 (2.5) 0.5††† 25.0††† 846 (1.5) 1,125 (2.0) 0.5††† 33.3††† American Indian/Alaska Native, non-Hispanic 56 (2.1) 65 (2.4) 0.3 14.3 181 (6.9) 222 (8.5) 1.6††† 23.2††† Asian/Pacific Islander, non-Hispanic 85 (0.4) 129 (0.6) 0.2 50.0 171 (0.8) 218 (1.0) 0.2††† 25.0††† U.S. Census region of residence Northeast 2,957 (5.3) 3,860 (7.0) 1.7††† 32.1††† 431 (0.8) 648 (1.2) 0.4††† 50.0††† Midwest 2,575 (3.9) 3,711 (5.6) 1.7††† 43.6††† 1,176 (1.9) 1,959 (3.1) 1.2††† 63.2†††` South 4,005 (3.3) 5,365 (4.4) 1.1††† 33.3††† 2,483 (2.1) 3,508 (3.0) 0.9††† 42.9††† West 838 (1.1) 1,006 (1.3) 0.2††† 18.2††† 3,452 (4.4) 4,218 (5.3) 0.9††† 20.5††† County urbanization level §§ Large central metro 4,301 (4.2) 5,513 (5.3) 1.1††† 26.2††† 2,561 (2.5) 3,178 (3.0) 0.5††† 20.0††† Large fringe metro 2,734 (3.5) 3,701 (4.7) 1.2††† 34.3††† 1,235 (1.6) 1,843 (2.3) 0.7††† 43.8††† Medium metro 2,082 (3.2) 2,945 (4.5) 1.3††† 40.6††† 1,821 (2.8) 2,672 (4.1) 1.3††† 46.4††† Small metro 569 (2.1) 777 (2.9) 0.8††† 38.1††† 698 (2.6) 972 (3.6) 1.0††† 38.5††† Micropolitan (non-metro) 474 (1.9) 740 (3.0) 1.1††† 57.9††† 745 (3.0) 994 (4.0) 1.0††† 33.3††† Non-core (non-metro) 215 (1.3) 266 (1.6) 0.3††† 23.1††† 482 (2.9) 674 (4.1) 1.2††† 41.4††† States with very good to excellent reporting ¶¶ (n = 27) Alaska 15§§§ 17§§§ §§§ §§§ 49 (6.3) 66 (9.1) 2.8 44.4 Connecticut 237 (6.9) 284 (8.4) 1.5††† 21.7††† 25 (0.7) 39 (1.2) 0.5 71.4 District of Columbia 89 (13.5) 122 (17.6) 4.1 30.4 §§§ §§§ §§§ §§§ Georgia 209 (2.0) 258 (2.4) 0.4 20.0 243 (2.4) 364 (3.6) 1.2††† 50.0††† Hawaii §§§ 10§§§ §§§ §§§ 102 (6.8) 106 (7.4) 0.6 8.8 Illinois 507 (4.0) 743 (5.7) 1.7††† 42.5††† 112 (0.9) 171 (1.4) 0.5††† 55.6††† Iowa 15§§§ 19§§§ §§§ §§§ 80 (2.7) 93 (3.3) 0.6 22.2 Maine 61 (5.0) 94 (7.7) 2.7 54.0 28 (2.3) 44 (3.8) 1.5 65.2 Maryland 314 (5.0) 532 (8.6) 3.6††† 72.0††† 43 (0.8) 65 (1.2) 0.4 50.0 Massachusetts 567 (8.5) 687 (10.1) 1.6††† 18.8††† 45 (0.7) 64 (1.0) 0.3 42.9 Nevada 37 (1.2) 50 (1.6) 0.4 33.3 228 (7.5) 257 (8.3) 0.8 10.7 New Hampshire 61 (5.0) 51 (3.9) −1.1 −22.0 13§§§ 26 (2.3) §§§ §§§ New Mexico 58 (3.0) 57 (2.9) −0.1 −3.3 135 (7.1) 158 (8.2) 1.1 15.5 New York 991 (4.9) 1,306 (6.5) 1.6††† 32.7††† 150 (0.8) 191 (1.0) 0.2††† 25.0††† North Carolina 500 (5.1) 708 (7.2) 2.1††† 41.2††† 115 (1.2) 176 (1.8) 0.6††† 50.0††† Ohio 1,124 (10.1) 1,556 (14.0) 3.9††† 38.6††† 243 (2.3) 556 (5.3) 3.0††† 130.4††† Oklahoma 31 (0.8) 45 (1.1) 0.3 37.5 263 (7.1) 275 (7.2) 0.1 1.4 Oregon 26 (0.7) 39 (0.9) 0.2 28.6 150 (3.6) 170 (4.0) 0.4 11.1 Rhode Island 112 (10.7) 111 (11.2) 0.5 4.7 10§§§ 12§§§ §§§ §§§ South Carolina 143 (3.0) 234 (4.7) 1.7††† 56.7††† 125 (2.7) 189 (4.0) 1.3††† 48.1††† Tennessee 249 (3.8) 306 (4.6) 0.8††† 21.1††† 186 (2.9) 320 (5.0) 2.1††† 72.4††† Utah 48 (1.7) 47 (1.5) −0.2 −11.8 143 (5.1) 198 (6.8) 1.7††† 33.3††† Vermont 21 (4.0) 38 (6.9) 2.9 72.5 §§§ §§§ §§§ §§§ Virginia 254 (3.0) 351 (4.1) 1.1††† 36.7††† 76 (0.9) 113 (1.4) 0.5 55.6 Washington 90 (1.2) 111 (1.4) 0.2 16.7 326 (4.4) 392 (5.2) 0.8††† 18.2††† West Virginia 143 (8.5) 191 (11.6) 3.1††† 36.5††† 117 (7.0) 221 (13.6) 6.6††† 94.3††† Wisconsin 147 (2.6) 265 (4.8) 2.2††† 84.6††† 76 (1.4) 128 (2.3) 0.9††† 64.3††† States with good reporting ¶¶ (n = 8) Arizona 82 (1.2) 136 (2.0) 0.8††† 66.7††† 454 (6.7) 572 (8.5) 1.8††† 26.9††† California 366 (0.9) 433 (1.0) 0.1 11.1 1,579 (3.8) 1,916 (4.6) 0.8††† 21.1††† Colorado 106 (1.9) 96 (1.7) −0.2 −10.5 200 (3.6) 301 (5.2) 1.6††† 44.4††† Kentucky 145 (3.5) 185 (4.3) 0.8 22.9 192 (4.7) 330 (8.0) 3.3††† 70.2††† Michigan 500 (5.3) 643 (6.7) 1.4††† 26.4††† 88 (0.9) 145 (1.6) 0.7††† 77.8††† Minnesota 43 (0.8) 68 (1.3) 0.5 62.5 140 (2.6) 161 (2.9) 0.3 11.5 Missouri 103 (1.8) 132 (2.2) 0.4 22.2 185 (3.3) 248 (4.3) 1.0††† 30.3††† Texas 584 (2.1) 694 (2.4) 0.3††† 14.3††† 577 (2.1) 653 (2.3) 0.2 9.5 Source: National Vital Statistics System, Mortality File. https://wonder.cdc.gov/. * Deaths are classified using the International Classification of Diseases, Tenth Revision (ICD–10). Drug overdose deaths are 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 cocaine (T40.5) as a contributing cause. § Drug overdose deaths, as defined, that have psychostimulants with abuse potential (T43.6) as a contributing cause. ¶ Categories of deaths are not exclusive because deaths might involve more than one drug. Summing of categories will result in more than the total number of deaths in a year. ** Drug overdose deaths, as defined, that have any opioid (T40.0–T40.4, and T40.6). †† 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 2013 urbanization classification https://www.cdc.gov/nchs/data_access/urban_rural.htm. ¶¶ Analyses were limited to states meeting the following criteria: For states with very good to excellent reporting, ≥90% of drug overdose deaths mention at least one specific drug in 2016, with the change in drug overdose deaths mentions of at least one specific drug differing by <10 percentage points between 2016 and 2017. States with good reporting had 80% to <90% of drug overdose deaths mention of at least one specific drug in 2016, with the change in the percentage of drug overdose deaths mentioning at least one specific drug differing by <10 percentage points between 2016 and 2017. States included also were required to have stable rate estimates, based on ≥20 deaths, in at least one drug category (i.e., cocaine and psychostimulants with abuse potential) in both 2016 and 2017. *** Absolute rate change is the difference between 2016 and 2017 rates. Percentage change (i.e., relative change) is the absolute rate change divided by the 2016 rate, multiplied by 100. Nonoverlapping confidence intervals based on the gamma method were used if the number of deaths was <100 in 2016 or 2017, and z-tests were used if the number of deaths was ≥100 in both 2016 and 2017. Note that the method of comparing confidence intervals is a conservative method for statistical significance; caution should be observed when interpreting a nonsignificant difference when the lower and upper limits being compared overlap only slightly. Confidence intervals for 2016 and 2017 rates of cocaine-involved deaths for Asian/Pacific Islanders overlapped only slightly: (0.35–0.54), (0.53–0.76) Confidence intervals of 2016 and 2017 rates of deaths involving psychostimulants with abuse potential for Virginia overlapped only slightly: (0.71–1.13), (1.10–1.60). ††† Statistically significant (p-value <0.05). §§§ Data with <10 deaths are not reported. Rates based on <20 deaths are not considered reliable and not reported. During 2003–2017, rates for all cocaine-involved deaths peaked initially in 2006, decreased during 2006–2012, and increased again during 2012–2017. Rates of overdose deaths involving cocaine and any opioid increased from 2013 to 2017, and those involving cocaine and synthetic opioids increased from 2012 to 2017 (Figure 1). Cocaine-involved death rates without any opioid decreased from 2006 to 2012 and then increased from 2012 to 2017, whereas cocaine-involved death rates without synthetic opioids increased from 2003 to 2006, decreased from 2006 to 2010, and then increased from 2010 to 2017 (Figure 1). FIGURE 1 Age-adjusted rates* of drug overdose deaths † involving cocaine § with and without synthetic opioids other than methadone (synthetic opioids) and any opioids ¶ — United States, 2003–2017** , †† Source: National Vital Statistics System, Mortality File. https://wonder.cdc.gov/. * Rate per 100,000 population age-adjusted to the 2000 U.S. standard population using the vintage year population of the data year. † Deaths are classified using the International Classification of Diseases, Tenth Revision (ICD-10). 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 cocaine (T40.5). ¶ Drug overdose deaths, as defined, that involve any opioid (T40.0–T40.4 and T40.6) and synthetic opioids other than methadone (T40.4). ** Because deaths might involve more than one drug, some deaths are included in more than one category. In 2017, 12% of drug overdose deaths did not include information on the specific type of drug(s) involved. Some of these deaths might have involved opioids or stimulants. †† Joinpoint regression examining changes in trends during 2003–2017 indicated that cocaine-involved overdose death rates remained stable from 2003 to 2006, then decreased annually by 10.8% (95% confidence interval [CI] = −18.1 to −3.0) from 2006 to 2012, followed by a 28.5% (CI = 19.8–37.9) annual increase from 2012 to 2017. Death rates involving cocaine and any opioid remained stable from 2003 to 2013, then increased annually by 41.6% (CI = 29.1–55.2) from 2013 to 2017. Death rates involving cocaine and synthetic opioids remained stable from 2003 to 2012, then increased annually by 114.2% (CI = 82.5–151.5) from 2012 to 2017. Death rates involving cocaine without any opioid remained stable from 2003 to 2006, then decreased annually by 13.8% (CI = −21.5 to −5.3) from 2006 to 2012, followed by a 14.9% (CI = 4.8–26.1) annual increase from 2012 to 2017. Death rates involving cocaine without synthetic opioids increased annually by 11.4% (CI = 2.1–21.6) from 2003 to 2006, then decreased annually by 14.9% (CI = −22.2 to −7.0) from 2006 to 2010, followed by a 6.9% annual increase (CI = 4.4–9.4) from 2010 to 2017. The figure consists of two line graphs, one showing the rate of overdose deaths involving cocaine with opioids per 100,000 population, and the other showing the rate of overdose deaths involving cocaine without opioids, per 100,000 population, in the United States during 2003–2017. In 2017, a total of 10,333 deaths involving psychostimulants occurred, representing 14.7% of drug overdose deaths and a 37.0% increase from 2016 (Table). During 2016–2017, the age-adjusted rate for psychostimulant-involved deaths increased by 33.3%. Approximately half (50.4%) of psychostimulant-involved deaths also involved opioids in 2017. Psychostimulant-involved death rates increased among both sexes and among persons aged ≥15 years, whites, blacks, non-Hispanic American Indians/Alaska Natives (AI/AN), non-Hispanic Asian/Pacific Islanders (A/PI), and Hispanics. The largest relative rate increase occurred among females aged 25–44 years (48.0%). Among racial/ethnic groups, the largest relative rate increase occurred among whites (40.0%), whereas AI/AN experienced the largest absolute rate increase (1.6 per 100,000) and the highest death rate (8.5) in 2017. Counties in medium metro areas experienced the largest absolute rate increase (1.3 per 100,000), and the largest relative rate increase (46.4%). Among Census regions, both the largest relative increase (63.2%) and the largest absolute rate increase (1.2) occurred in the Midwest, whereas the highest psychostimulant-involved death rate (5.3) occurred in the West. Death rates increased in 17 states, with the largest relative increases in Ohio (130.4%) and West Virginia (94.3%), and the largest absolute rate increases in West Virginia (6.6 per 100,000) and Kentucky (3.3). In 2017, the highest death rates were in West Virginia (13.6 per 100,000) and Alaska (9.1). During 2003–2017, rates for all psychostimulant-involved deaths increased from 2010 to 2017. Death rates involving psychostimulants and any opioid increased from 2003 to 2010, followed by sharper increases from 2010 to 2015 and from 2015 to 2017. Death rates involving psychostimulants and synthetic opioids increased from 2010 to 2015, followed by a sharper increase from 2015 to 2017 (Figure 2). Rates of psychostimulant-involved deaths without any opioid involvement increased from 2008 to 2017, and rates without synthetic opioid involvement increased from 2008 to 2017 (Figure 2). FIGURE 2 Age-adjusted rates* of drug overdose deaths † involving psychostimulants with abuse potential § (psychostimulants) with and without synthetic opioids other than methadone (synthetic opioids) and any opioids ¶ — United States, 2003–2017** , †† Source: National Vital Statistics System, Mortality File. https://wonder.cdc.gov/. * Rate per 100,000 population age-adjusted to the 2000 U.S. standard population using the vintage year population of the data year. † Deaths are classified using the International Classification of Diseases, Tenth Revision (ICD-10). 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 psychostimulants with abuse potential (T43.6). ¶ Drug overdose deaths, as defined, that involve any opioid (T40.0-T40.4, and T40.6) and synthetic opioids other than methadone (T40.4). ** Because deaths might involve more than one drug, some deaths are included in more than one category. In 2017, 12% of drug overdose deaths did not include information on the specific type of drug(s) involved. Some of these deaths may have involved opioids or stimulants. †† Joinpoint regression examining changes in trends during 2003–2017 indicated that psychostimulant-involved overdose death rates remained stable from 2003 to 2010, then increased annually by 28.6% (95% confidence interval [CI] = 25.5–31.8) from 2010 to 2017. Death rates involving psychostimulants and any opioid increased annually by 6.9% (CI = 1.0–13.1) from 2003 to 2010, then increased annually by 28.2% (CI = 18.2–39.1) from 2010 to 2015, followed by a 50.8% (CI = 31.6–72.8) annual increase from 2015 to 2017. Death rates involving psychostimulants and synthetic opioids were greater than zero only during 2010–2017. From 2010 to 2015, these rates increased annually by 44.7% (CI = 2.8–103.5), followed by a 142.8% (CI = 43.7–310.2) annual increase from 2015 to 2017. Death rates involving psychostimulants without any opioids remained stable from 2003 to 2008, then increased annually by 22.3% (CI = 20.6–24.0) from 2008 to 2017. Death rates involving psychostimulants without synthetic opioids remained stable from 2003 to 2008, then increased annually by 22.3% (CI = 20.7–23.9) from 2008 to 2017. The figure consists of two line graphs, one showing the rate of drug overdose deaths involving psychostimulants with abuse potential with synthetic opioids other than methadone, and the other showing the rate of overdose deaths involving psychostimulants with abuse potential without synthetic opioids other than methadone, per 100,000 population, in the United States during 2003–2017. Discussion Deaths involving cocaine and psychostimulants have increased in the United States in recent years; among 70,237 drug overdose deaths in 2017, nearly a third (23,139 [32.9%]) involved cocaine, psychostimulants, or both. From 2016 to 2017, death rates involving cocaine and psychostimulants each increased by approximately one third, and increases occurred across all demographic groups, Census regions, and in several states. In 2017, nearly three fourths of cocaine-involved and roughly one half of psychostimulant-involved overdose deaths, respectively, involved at least one opioid. After initially peaking in 2006, trends in overall cocaine-involved death rates declined through 2012, when they began to rise again. The 2006–2012 decrease paralleled a decline in cocaine supply coupled with an increase in cost. ¶¶¶ Similar patterns in death rates involving both cocaine and opioids were observed, with increases for cocaine- and synthetic opioid-involved deaths occurring from 2012 to 2017. From 2010 to 2017, increasing rates of deaths involving psychostimulants occurred and persisted even in the absence of opioids. Drug overdoses continue to evolve along with emerging threats, changes in the drug supply, mixing of substances with or without the user’s knowledge, and polysubstance use ( 3 – 8 ). In addition, the availability of psychostimulants, particularly methamphetamine, appears to be increasing across most regions.**** In 2017, among drug products obtained by law enforcement that were submitted for laboratory testing, methamphetamine and cocaine were the most and third most frequently identified drugs, respectively. †††† Previous studies also found that heroin and synthetic opioids (e.g., illicitly-manufactured fentanyl) have contributed to increases in stimulant-involved deaths ( 3 , 9 , 10 ). Current findings further support that increases in stimulant-involved deaths are part of a growing polysubstance landscape. Although synthetic opioids appear to be driving much of the increase in cocaine-involved deaths, increases in psychostimulant-involved deaths have occurred largely without opioid co-involvement; however, recent data suggest increasing synthetic opioid involvement in these deaths. The findings in this report are subject to at least four limitations. First, at autopsy, substances tested for and circumstances under which tests are performed vary by time and jurisdiction. Therefore, recent improvements in toxicologic testing might account for some reported increases. Second, 15% and 12% of death certificates in 2016 and 2017, respectively, did not include mention of specific drugs involved. The percentage of death certificates with at least one drug specified varied widely by state, ranging from 54.7% to 99.3% in 2017, limiting comparisons across states. Third, potential racial misclassification might lead to underestimates for certain groups, primarily AI/AN and A/PI. §§§§ Finally, certain trend analyses were limited, given small numbers of deaths and the inability to calculate stable rates among some stimulant-opioid drug combinations before 2003. Preliminary 2018 data indicate continued increases in drug overdose deaths. ¶¶¶¶ The rise in deaths involving cocaine and psychostimulants and the continuing evolution of the drug landscape indicate a need for a rapid, multifaceted, and broad approach that includes more timely and comprehensive surveillance efforts to inform tailored and effective prevention and response strategies. CDC currently funds 45 states and DC for opioid surveillance***** and/or prevention activities. ††††† The contribution of opioids to increases in stimulant-involved overdose deaths underscores the importance of continued opioid overdose surveillance and prevention measures, including existing efforts to expand naloxone availability to persons at risk for drug overdose. CDC is expanding drug overdose surveillance efforts to include stimulants and is implementing multiple, evidence-based opioid prevention efforts, such as enhancing linkage to care, building state and local capacity, and public health/public safety collaborations. §§§§§ Because some stimulant deaths are also increasing without opioid co-involvement, prevention and response strategies need to evolve accordingly. Increased efforts are required to identify and improve access to care for persons using stimulants, implement upstream prevention efforts focusing on shared risk and protective factors that address substance use/misuse, and improve risk reduction messaging (e.g., not using alone). Continued collaborations among public health, public safety, and community partners are critical to understanding the local illicit drug supply and reducing risk as well as linking persons to medication-assisted treatment and risk-reduction services. Summary What is already known about this topic? Overdose deaths involving cocaine and psychostimulants continue to increase. During 2015–2016, age-adjusted cocaine-involved and psychostimulant-involved death rates increased by 52.4% and 33.3%, respectively. What is added by this report? From 2016 to 2017, death rates involving cocaine and psychostimulants increased across age groups, racial/ethnic groups, county urbanization levels, and multiple states. Death rates involving cocaine and psychostimulants, with and without opioids, have increased. Synthetic opioids appear to be the primary driver of cocaine-involved death rate increases, and recent data point to increasing synthetic opioid involvement in psychostimulant-involved deaths. What are the implications for public health practice? Continued increases in stimulant-involved deaths require expanded surveillance and comprehensive, evidence-based public health and public safety interventions.

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Overdose Deaths Involving Opioids, Cocaine, and Psychostimulants — United States, 2015–2016

Puja Seth, Lawrence E. Scholl, Rose A Rudd … (2018)

During 1999‒2015, 568,699 persons died from drug overdoses in the United States.* Drug overdose deaths in the United States increased 11.4% from 2014 to 2015 resulting in 52,404 deaths in 2015, including 33,091 (63.1%) that involved an opioid. The largest rate increases from 2014 to 2015 occurred among deaths involving synthetic opioids other than methadone (synthetic opioids) (72.2%) ( 1 ). Because of demographic and geographic variations in overdose deaths involving different drugs ( 2 , 3 ), † CDC examined age-adjusted death rates for overdoses involving all opioids, opioid subcategories (i.e., prescription opioids, heroin, and synthetic opioids), § cocaine, and psychostimulants with abuse potential (psychostimulants) by demographics, urbanization levels, and in 31 states and the District of Columbia (DC). There were 63,632 drug overdose deaths in 2016; 42,249 (66.4%) involved an opioid. ¶ From 2015 to 2016, deaths increased across all drug categories examined. The largest overall rate increases occurred among deaths involving cocaine (52.4%) and synthetic opioids (100%), likely driven by illicitly manufactured fentanyl (IMF) ( 2 , 3 ). Increases were observed across demographics, urbanization levels, and states and DC. The opioid overdose epidemic in the United States continues to worsen. A multifaceted approach, with faster and more comprehensive surveillance, is needed to track emerging threats to prevent and respond to the overdose epidemic through naloxone availability, safe prescribing practices, harm-reduction services, linkage into treatment, and more collaboration between public health and public safety agencies. Drug overdose deaths were identified in the National Vital Statistics System multiple cause-of-death mortality files,** using the International Classification of Diseases, Tenth Revision (ICD-10), based on ICD-10 underlying cause-of-death codes X40–44 (unintentional), X60–64 (suicide), X85 (homicide), or Y10–Y14 (undetermined intent). Among deaths with drug overdose as the underlying cause, the type of drug or drug category is indicated by the following ICD-10 multiple cause-of-death codes: opioids (T40.0, T40.1, T40.2, T40.3, T40.4, or T40.6) †† ; natural/semisynthetic opioids (T40.2); methadone (T40.3); heroin (T40.1); synthetic opioids other than methadone (T40.4); cocaine (T40.5); and psychostimulants with abuse potential (T43.6). Some deaths involved more than one type of drug; these deaths were included in the rates for each drug category. Therefore, categories are not mutually exclusive. §§ Age-adjusted overdose death rates ¶¶ were examined for 2015 and 2016 for all opioids, opioid subcategories (prescription opioids [i.e., natural/semisynthetic opioids and methadone] ( 4 ), heroin, and synthetic opioids), cocaine, and psychostimulants in the United States and by age, sex, racial/ethnic group, urbanization level,*** and state. State-level analyses included 31 states and DC that met the following criteria: 1) ≥80% of drug overdose death certificates named at least one specific drug in 2015 and 2016; 2) change from 2015 to 2016 in the percentage of death certificates reporting at least one specific drug was 10 percentage points in drug specificity. ¶¶ Absolute rate change is the difference between 2015 and 2016 rates. Percent change is the absolute rate change divided by the 2015 rate, multiplied by 100. Nonoverlapping confidence intervals based on the gamma method were used if the number of deaths was 10 percentage points in drug specificity. ¶¶ Absolute rate change is the difference between 2015 and 2016 rates. Percent change is the absolute rate change divided by the 2015 rate, multiplied by 100. Nonoverlapping confidence intervals based on the gamma method were used if the number of deaths was 10 percentage points in drug specificity. ¶¶ Absolute rate change is the difference between 2015 and 2016 rates. Percent change is the absolute rate change divided by the 2015 rate, multiplied by 100. Nonoverlapping confidence intervals based on the gamma method were used if the number of deaths was <100 in 2015 or 2016, and z-tests were used if the number of deaths was ≥100 in both 2015 and 2016. *** Statistically significant at 0.05 level. ††† Cells with ≤9 deaths are not reported. Rates based on <20 deaths are not considered reliable and not reported. From 2015 to 2016, opioid-involved deaths increased in males and females and among persons aged ≥15 years, whites, blacks, Hispanics, and Asian/Pacific Islanders. The largest relative rate change occurred among blacks (56.1%) (Table 1). The largest absolute rate increases of opioid-involved deaths and deaths involving synthetic opioids occurred among males aged 25–44 years and persons aged 25–34 years. However, deaths involving synthetic opioids increased in every subgroup examined (Table 2). Rates involving prescription opioids, heroin, cocaine, and psychostimulants increased for both sexes, whites, blacks, and most age groups (Table 1) (Table 2) (Table 3). Counties in large central and fringe metro areas experienced the largest absolute increases in deaths involving prescription and synthetic opioids, heroin, and cocaine; micropolitan areas experienced the largest increase in rates involving psychostimulants (Table 1) (Table 2) (Table 3). Opioid death rates differed across the 31 states and DC, with synthetic opioids driving increases in many states. ¶¶¶ Although several states experienced increases across drug categories, in many, the changes from 2015 to 2016 were not significant. Rates of deaths involving synthetic opioids ranged from 0.9 to 30.3 per 100,000, with the largest rates and increases concentrated in eastern states. New Hampshire (30.3 per 100,000), West Virginia (26.3), and Massachusetts (23.5) had the highest synthetic opioid death rates. Twenty states and DC experienced increases in overdose death rates involving synthetic opioids, with 10 experiencing increases by ≥100%; the largest such increase (392.3%) occurred in DC, followed by Illinois (227.3%) and Maryland (206.9%) (Table 2). Many states with large increases in synthetic opioid death rates also had large increases in rates involving other drug categories (e.g., Maryland, Virginia, and DC), including any opioid, prescription opioids (Table 1), heroin (Table 2), and cocaine (Table 3). Thirteen states and DC experienced significant increases in heroin-involved death rates, whereas a significant decrease (56.9%) occurred in New Hampshire (Table 2). In 2016, the highest rates were in DC (17.3 per 100,000), West Virginia (14.9), and Ohio (13.5). The rates of prescription opioid–involved overdose deaths significantly increased in seven states and DC, with the highest rates in West Virginia (19.7), Maryland (13.1), Maine (12.5), and Utah (12.5) (Table 1). The highest cocaine-involved overdose death rates occurred in DC (13.5), Rhode Island (10.7), and Ohio (10.1), with 15 states and DC experiencing a significant increase from 2015 (Table 3). Significant increases in overdose death rates from heroin, prescription opioids, and cocaine occurred primarily in states in the eastern part of the country. Fourteen states experienced significant increases in psychostimulant-involved overdose death rates. The highest rates were in midwestern and western states: Nevada (7.5), New Mexico (7.1), and Oklahoma (7.1) (Table 3). Discussion Drug overdoses resulted in 632,331 deaths from 1999 to 2016 in the United States, with 351,630 being opioid overdose deaths.**** The epidemic has continued to worsen, with deaths increasing from 2015 to 2016 across all drug categories examined. Opioid-involved overdoses accounted for two thirds of drug overdose deaths, with increases across age and racial/ethnic groups, urbanization levels, and in numerous states. The findings highlight wide state and regional variations. Some states (e.g., New Hampshire, Ohio, and West Virginia,) experienced the highest overdose death rates across multiple drug categories, and others (primarily in the Midwest and West) recorded the highest rates of psychostimulant-involved overdose deaths. In New Hampshire, although heroin-involved death rates declined from 2015 to 2016, deaths involving synthetic opioids increased, as they did in most states. In addition, in some states (e.g., Maryland, Rhode Island, and West Virginia), 2016 rates of prescription opioid–involved deaths were higher than were those involving heroin. These data highlight the persistent and multifaceted nature of overdoses. The first wave of opioid overdose deaths began in the 1990s and included prescription opioid deaths. †††† A second wave, which began in 2010, was characterized by heroin deaths ( 5 ). A third wave started in 2013, with deaths involving highly potent synthetic opioids, particularly IMF and fentanyl analogs ( 2 , 3 , 6 ). §§§§ Synthetic opioid-involved deaths in 2016 accounted for 30.5% of all drug overdose deaths and 45.9% of all opioid-involved deaths, with a 100% increase in the rate of these deaths compared with 2015. Synthetic opioids propelled increases with 19,413 deaths (more than any drug examined), and previous findings underscore the contribution of IMF. In addition, IMF is now being mixed into counterfeit opioid and benzodiazepine pills, heroin, and cocaine, likely contributing to increases in overdose death rates involving other substances ( 3 , 7 , 8 ). The findings in this report are subject to at least five limitations. First, at autopsy, substances tested for, and circumstances under which tests are performed to determine which drugs are present, vary by time and jurisdiction, and improvements in toxicologic testing might account for some reported increases. Second, 17% (2015) and 15% (2016) of drug overdose death certificates did not include the specific types of drugs involved, and the percentage of drug overdose death certificates with at least one drug specified varied widely by state, ranging from 52.5% to 99.3% in 2016. This variation limits rate comparisons between states. Third, because heroin and morphine are metabolized similarly ( 9 ), some heroin deaths might have been misclassified as morphine deaths, resulting in underreporting of heroin deaths. Fourth, potential race misclassification might lead to underestimates for certain categories, primarily for American Indian/Alaska Natives and Asian/Pacific Islanders. ¶¶¶¶ Finally, state-specific analyses are restricted to 31 states and DC, limiting generalizability. The ongoing and worsening drug overdose epidemic requires immediate attention and action. Faster access to data collected is needed to understand emerging threats in local communities and to tailor response activities. CDC’s Enhanced State Opioid Overdose Surveillance program funds 32 states and DC for more timely and comprehensive nonfatal and fatal overdose data, including funding for improved comprehensive toxicologic testing to identify emerging drug threats in opioid-involved fatal overdoses.***** Syndromic surveillance data allow communities to identify overdoses quickly ( 10 ). The State Unintentional Drug Overdose Reporting System provides improved collection of toxicology data to identify specific drugs involved ( 6 ), information gathered from death scene investigations, and risk factors associated with fatal overdoses. Given the continuing threat from prescription opioids and the evolving threat from illicit opioids and other substances, a multifaceted prevention approach is required. Efforts to ensure safe prescribing practices ††††† are enhanced by access to nonopioid and nonpharmacologic treatments for pain. Other important efforts include increasing naloxone availability, expanding access to medication-assisted treatment, and maximizing the ability of health systems to link persons to treatment and harm reduction services ( 10 ). CDC supports many of these efforts through the Prevention for States and Data-Driven Prevention Initiatives, §§§§§ which together support opioid overdose prevention efforts in 42 states and DC. Collaboration with law enforcement, first responders, and harm reduction partners is also important to understanding local variations in drug supply and lethality and to implementing a multisectoral prevention approach. Summary What is already known about this topic? From 1999 to 2015, the drug overdose epidemic resulted in approximately 568,699 deaths. In 2015, 52,404 drug overdose deaths occurred; 63.1% (33,091) involved an opioid. From 2014 to 2015, the age-adjusted opioid-involved death rate increased by 15.6%; the rapid increase in deaths was driven in large part by synthetic opioids other than methadone (e.g., fentanyl). What is added by this report? In 2016, there were 63,632 drug overdose deaths in the United States. Opioids accounted for 66.4% (42,249) of deaths, with increases across age groups, racial/ethnic groups, urbanization levels, and multiple states. Age-adjusted death rates for overdoses involving synthetic opioids other than methadone doubled from 2015 to 2016, and death rates from prescription opioids, heroin, cocaine, and psychostimulants also increased. What are the implications for public health practice? There is an urgent need to implement a multifaceted, collaborative public health and public safety approach. Building on existing resources, more rapidly available and comprehensive surveillance data are needed to track emerging drug threats to guide public action to prevent and respond to the epidemic through increased naloxone availability, harm reduction services, linkage into treatment (including medication-assisted treatment), safe prescribing practices, and supporting law enforcement strategies to reduce the illicit drug supply.

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Journal ID (nlm-ta): MMWR Morb Mortal Wkly Rep

Journal ID (iso-abbrev): MMWR Morb Mortal Wkly Rep

Journal ID (publisher-id): WR

Title: Morbidity and Mortality Weekly Report

Publisher: Centers for Disease Control and Prevention

ISSN (Print): 0149-2195

ISSN (Electronic): 1545-861X

Publication date (Electronic): 12 February 2021

Publication date Collection: 12 February 2021

Volume: 70

Issue: 6

Pages: 202-207

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Division of Overdose Prevention, National Center for Injury Prevention and Control, CDC; Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee.

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Corresponding authors: Christine L. Mattson, ggi8@ 123456cdc.gov ; Lauren J. Tanz, okp1@ 123456cdc.gov .

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Publisher ID: mm7006a4

DOI: 10.15585/mmwr.mm7006a4

PMC ID: 7877587

PubMed ID: 33571180

SO-VID: df353d18-89b3-4eb1-abde-781c7ebbc9f5

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All material in the MMWR Series is in the public domain and may be used and reprinted without permission; citation as to source, however, is appreciated.

Trends and Geographic Patterns in Drug and Synthetic Opioid Overdose Deaths — United States, 2013–2019

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Drug and Opioid-Involved Overdose Deaths — United States, 2017–2018

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Overdose Deaths Involving Opioids, Cocaine, and Psychostimulants — United States, 2015–2016

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