Tuesday, February 19, 2013

Drug Overdose Deaths Still Rising in U.S.

In The NewsAccording to newly-published data, drug overdose deaths increased for the 11th straight year in 2010, and increases associated with opioid analgesics are of special concern. However, other pharmaceuticals are frequently involved in opioid-related overdose deaths, and the contribution of these nonopioid Rx-drugs — often used for treating mental health and pain conditions — merits immediate and ongoing attention.

Writing in the February 20, 2013 edition of the Journal of the American Medical Association, Christopher Jones, PharmD, and colleagues at the U.S. Centers for Disease Control and Prevention (CDC), report using data from the National Vital Statistics System to examine the specific drugs involved in pharmaceutical and opioid-related overdose deaths [Jones et al. 2013. The authors found that, in 2010, there were at total 38,329 drug overdose deaths in the United States and most of those involved pharmaceutical products (58%; 22,134). [Note: all percentages in this UPDATE are rounded for convenience.]

Of the pharmaceutical-related overdose deaths, roughly 75% were accidental, 17% were suicides, and another 8% were of undetermined intent. Prescription-drug classes most commonly involved in pharmaceutical overdose deaths — either alone or in combination with other drugs — included: opioids (75% of cases; 16,651 deaths), benzodiazepines (29%; 6,497), antidepressants (18%; 3,889), antiepileptic and anti-parkinsonism drugs (8%; 1,717), and others.

Among all overdose deaths involving a psychotherapeutic or central nervous system pharmaceutical as a sole agent, opioids alone were implicated to the greatest extent (29%; or 4,903/16,651). At the same time, opioids were often implicated in overdose deaths involving other pharmaceuticals. Opioids were co-agents present in a majority of deaths involving benzodiazepines (77%); antiepileptic and antiparkinsonism drugs (66%); antipsychotic and neuroleptic drugs (58%); antidepressants (58%); other analgesics, antipyretics, and antirheumatics (57%); and other psychotropic drugs (54%).

The authors conclude that their analysis confirms a dominant role of opioid analgesics in drug overdose deaths, either alone or in combination with other agents. However, it also highlights the frequent involvement in overdose deaths of pharmaceuticals — such as benzodiazepines, antidepressants, and antipsychotics — typically prescribed for mental health conditions. Persons with mental health disorders are at increased risk for heavy therapeutic use, nonmedical use, and overdose of opioids; therefore, screening, identification, and appropriate management of such disorders is an important part of both behavioral health and chronic pain management.

CDCCOMMENTARY: In previous UPDATES [eg, here], we have expressed some concern about potential biases in government data and how those must be considered circumspectly. Government reports tend to present so much data, often in such subtle ways, that it is understandable why the numbers can be confusing and distorted in the news media.

To help clarify the data, it is important to note in the above discussion that the 38,329 figure represents all drug overdose deaths in 2010. Of those, 22,134 or 58% involved pharmaceutical products — almost all were prescription drugs, but a “small minority” were over-the-counter or illicit drugs, according to the report. Looking further, 16,651 of pharmaceutical-associated mortality cases involved prescription opioid analgesics; however, opioids were a sole agent in only 4,903 overdose deaths.

Jones et al. concede that there are limitations of their report due to inadequacies of death certificates used for data gathering. For example, in a quarter of coroner or medical examiner reports of drug overdoses the type of drugs involved were not specified, and this might result in considerable variation and inaccuracies in the data. Also, the data do not distinguish between opioids like methadone or buprenorphine used for analgesia versus in maintenance therapy for addiction.

Despite such limitations, it is still of concern that the incidences of opioid-analgesic-related overdose deaths are rising. A prior report from the CDC noted that there were 14,800 such deaths in 2008 [discussed in UPDATE here], and the 16,651 for 2010 represents a 12.5% increase in just two years.

At the same time, it is very important to note that opioid analgesics are only one part of a larger drug overdose problem in the U.S. As a sole agent, opioids represent only about 13% (4,903/38,329) of all drug-related overdose deaths. So, the vast majority of cases implicate additional drugs; although, from this latest CDC data, we cannot determine the proportions of patients receiving pharmacotherapy for either chronic pain or mental health problems alone or in combination, and whether the involved opioid was prescribed for the decedent or was illicitly obtained.

Additional data in the CDC’s National Vital Statistics Reports [Hoyert and Xu 2012] provide further perspectives of some interest:

  • There were 33,041 deaths in 2010 due to accidental poisoning and exposure to “noxious substances,” or only 14% fewer than associated with drugs and nearly 50% more than pharmaceutical-associated deaths.

  • In 2010, there were 40,393 alcohol-induced deaths, or 5% more than those attributed to all other drugs. That year, there were 15,990 deaths due to alcoholic liver disease alone, almost matching those associated with opioids. It is interesting that deaths associated with this single drug, alcohol, do not get anywhere near the mass media and other attention devoted to opioids.

  • There were 38,364 suicides in 2010, roughly equaling deaths associated with all drugs. About half of those suicides involved a firearm and the remainder were by other means (including intentional drug overdoses). It is not known from the data how many of the suicides were among persons with intractable pain that became intolerable, or how many specifically involved opioids. As we previously discussed in an UPDATE [here], suicide ideation and attempts, and completed suicides among persons with chronic pain are inordinately high.

  • Speaking of firearms — an issue of some national angst these days — there were 16,259 homicides in 2010 (a number similar to opioid-related deaths), and 68% involved assault with discharge of firearms.

First, it is important to observe that poisonings, suicides, alcohol, and homicides represent major causes of deaths in the U.S. that are potentially preventable, just as might be drug overdoses. Second, all are increasing problems in society today. Third, if opioid-related problems are of “epidemic” proportions, as some government agencies have proclaimed, then those other problems also might be considered epidemics in society worthy of immediate attention.

The latest CDC data in the JAMA article by Jones et al. also suggests that the current focus on opioid analgesics is shortsighted in overlooking broader problems associated with a range of Rx-drugs used in mental health and pain management. Many of those drugs may have misuse, abuse, and overdose potential on their own, and they can become particularly lethal when combined with opioids and/or alcohol.

Therefore, addressing problems with opioid analgesics is only one part of the solution. And, of added concern, while we and others have advocated for widespread availability of the opioid-overdose antidote, naloxone [eg, here], this rescue medication would be ineffective for reversing the fatal effects of toxicity from nonopioid drugs and alcohol. As we have stressed before, problems of drug overdose deaths are multifaceted and complex; simplistic solutions or targeting a single class of drug are untenable strategies.

> Hoyert DL, Xu J. Deaths: Preliminary Data for 2011 [2010 final data]. National Vital Statistics Reports. 2012(Oct);61(6) [
PDF available here].
> Jones CM, Mack KA, Paulozzi LJ. Pharmaceutical Overdose Deaths, United States, 2010. JAMA. 2013 (Feb 20);309(7):657-659 [
article here].

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Russell said...

It would be interesting to find out several different questions.
I wonder how many of the opiate overdoses were chronic pain suffers who had been accused of faking their pain and released from the pain clinic they were attending. Then trying to get an appointment at a new one because they had been labeled a substance abuser and the excruciating pain has drove them to the very edge of their sanity. Thinking there were no other options they started trying illict drugs. Heroin overdoses are on the rise if I remember correctly, they decided they could stand the pain no longer. This person not knowing the strength decided they would try anything to escape the monster that kept growing within them and an overdose occured. The government can spin things anyway they want. I would like to see an independent study where the government kept their nose in their own business for a change and quit trying to police the whole damn world. I have suffered debilitating pain for the last 25 years and there have been times everything has crossed my mind to stop the monster called Chronic Pain. Chronic Pain is not near the ruthless name that should label that type of pain. I sit in a darkened room for 3 days, not sleeping at all during that time. Pistol in my hand, all I can say is God pulled me through that. I got a call from a psychiatrist who new my full history and knew I was not faking. He prescribed for me the following 3 weeks until I could get in to see the doctor I have now. I owe these 2 men my life because I couldn't of held out another 3 days I would have ended it. I know the dangers of the High Dose opiate treatment that still only holds my pain at a 6/10 on a really perfect day I may get it down to a 5. I would do anything to get the pain down to a 3 or even a 4 but my hands are tied. My pain doctor has a very extensive file of my pain records and I have told them I have even more and if the DEA ever goes after them because of me I will have an attorney and will get affidavits from friends, clergy, family all the ones that have seen me fight, kick and cry.
The really sad thing is my doctor hurts because I hurt but I will not ask them to jepordise their livilyhood because of me. My Endocronologist has said he doesn't know what has prevented me from having a heart attack because of the pain my arenal glands and pituatary glands are no where near where they should be, all the 16 years of steroid injections and oral steroids have fried them now my thyroid glands are not acting right. I went and bought my own heart rate monitor that one transmitter goes around my chest and the other part is a watch that preforms 72 functions if my heart rate gets to high and alarm will go off or if it gets to low an another alarm will go off. Well, I am in a lot of pain tonight and have a tendance to go on and on. One thing for sure the fight is almost gone out of me, I've fought this battle since 1978, good reason to be tired. The feds need to try stopping the drug cartels and let the men and women who know what the hell their doing fight the pain. God Bless.

Mark S. Barletta said...

I checked the population of U.S. citizens in July 1 of 1999 and there where 279.04 million people living in the U.S. This is about when the time released opioid medication where introduced to those that suffer from chronic pain for around the clock relief of never ending chronic pain.

And as of July 1, 2012 there are 313.85 million people living in the U.S. quite a increase in people, you do the math. With that comes thousands upon thousands more chronic pain sufferers looking for pain relief for their chronic pain. Also with this astounding increase of people comes those that abuse opioids for their pleasure and not that for what the medication is made.

We wonder why there is such a high increase in overdose deaths , must I write any further. With this increase in the population common sense would tell everyone the overdoses due to people abusing opioids for their pleasure comes these accidentally or unintentionally overdose deaths at a alarming rate.

Lets not blame Pain Specialist of America for the crises of opioid overdose deaths, blame the people that don’t have any business popping pills in their mouth they don’t need. As a result making it harder for true pain sufferers find relief from their ongoing chronic pain.

Seems every Monday I receive a new email from Pain Topics – e – Notifications and with that comes yet another story on the out of control overdose deaths of those that abuse opioid medications and the story goes on about how to gain control over this mess. However I don’t think its just opioids to blame , we have a problem with mental health in the U.S. that needs better management and screening . Other pharmaceuticals in combination with opioids like benzodiazepines, antidepressants and antipsychotics can impact a already risky situation even worse mixing these medications with alcohol can cause a fatal overdose.

Mark S. Barletta

SB. Leavitt, MA, PhD said...

Well, thank you, Mr. Barletta, for your comments -- I think. First, don’t shoot the messenger -- we’re reporting on published data, not making it up. Secondly, a most important point in our UPDATE article above is that opioid analgesics are only one part of a very much larger problem, which includes psychiatric medications and alcohol. Very much the same thing that you are saying.

Mark S. Barletta said...

Dr. Leavitt,

Thanks for responding ,I think you read in to my message wrong ,I never meant to shoot the messenger ,I know all reporting is very good published data.
It’s the never ending blaming game of opioids for the death of people that abuse them that’s been out of control for some time now. We all know these medications are very powerful and we must respect this fact that it’s a privilege to be able to have opioid medications made to help people with chronic pain have a life worth living. It seems everyone wants to blame either the opioid or the doctor or the laws that they say are not strict enough, when really it’s the people that abuse these medications that are causing the problem. Its not like someone is shoving these medications in to their mouths, they know abusing these medications is wrong yet they continue to do so. Addiction is a disease as everyone knows and people cant blame opioids for the mess they or their loved ones get themselves in to, I think its time we all assume responsibility for our actions. Maybe then these overdose deaths will start to decline.
Sometimes I have a hard time expressing myself in a comment but I have all the best interest in mind. I just hope everyone can get control of themselves and stop this abuse of opioid medications.

Mark S. Barletta

Janice Reynolds said...

This article had greatly distressed me primarily because of the title and knowing most people would take it at face value. This is what I wrote to another group when the article in Medscape was sent to us.
It is It is unfortunate Medscape publishes stuff like this without commenting on the strengths and weaknesses of the study. It is what Pain Topics calls a “data-mining” study which means they have gone through existing records to come up with the conclusion they wanted (head of the CDC was the one who said “opioids should only be the last choice for pain management”). In this case the investigators used data from the National Vital Statistics System multiple cause-of-death file to examine the specific drugs involved in pharmaceutical and opioid-related overdose deaths so we don’t know if they were truly cause of death, if there other confounding factors, as well as other important things which make this type of evidence incredibly weak. They do identify some of the deaths were in combination with “other drugs” but nothing as to whether alcohol or illegal drugs were involved. Most importantly-nothing is explained as to whether these medications were prescribed or the person who died in fact their conclusions concern only people with pain or mental illness. I have a feeling (and of course this is just a belief of mine) is most of those deaths were not from prescribed medication. One question that this brings up as well is why is a death from overdose more important, more tragic, more whatever than a death from suicide because someone cannot live with the pain or their pain meds were taken from them? I really don’t understand it plus although the deaths are listed as overdoses were the opioids combined with another medication, illegal drug, alcohol, or a natural death? It brings to mind the 48 Hour show some years ago where the 14 year old dies of an overdose and although her tox screen is positive for 12 or 14 different medications, most of which were scheduled drugs the coroner can say emphatically death was caused by the OxyContin.
You covered a lot of points certainly better than I did. I also get the Journal of Palliative Medicine’s Briefings. They had a paragraph “The CDC reports opioids still major contributor to drug overdose deaths” and then a summary stating the study’s conclusions. I wrote them saying I believed it was a disservice not to at least address the possibility it was a poor study and possible bias. There answer is they are just presenting the information and everyone has to make their own decision. How many will just look at that headline and say “Oh, no, things are getting worse, what can we do to stop Prescription Drug abuse?” (never mind what they have so far is seriously detrimental to people with pain.

SB. Leavitt, MA, PhD said...

Thank you, Ms. Reynolds, for your comments. As we have repeatedly pointed out, the government definitely has an agenda and overwhelms the public with data, some are good and some need further clarification. The authors often concede deficiencies in their data, but these escape notice by the public and the news media. This opens the door for misinterpretations, driven by biases of individual news reporters or readers. It seems that every problem, especially those surrounding analgesic medications, is labeled an “epidemic” these days -- inciting fears in patients, practitioners, and the public at large. Clear-headed assessments of the evidence fall by the wayside, and we do our best to point out the fallacies of thinking and bring more balance into the discussion of these issues.

Helen said...

It bothers me terribly that my pain management doctor, a very kind man who tries so hard to provide pain relief for his chronic pain patients, is in danger of being closed down by the feds and may actually face prosecution. What an awful thing to do to a doctor who has only the best interests of his patients: their pain relief, when he prescribes opioids. Secondly, it frightens me to think I may have to face this nightmare, my pain, without the aid of my prescriptions.

I can only use those modalities covered by my insurance. Aging and an increasing number of pain producing conditions narrow my choices anyway.

Now, if I turned to alcohol for whatever pain relief it afforded me, I would not have to worry about doctors, prescriptions, insurance OR the government. Perhaps if they were allowed to tax pain meds, getting them would be a lot easier!!!

Believe me, I don't like being in a place where I have to use these things. However as my conditions keep worsening, knowing that I will soon have some relief is the only thing that gets me out of bed. If someone could wave a wand and heal my back, my knees, my side, my age, I would drop the meds just as soon as the changes happened. I am sure I am not the only one.

Keep up the good fight; there are not many who would step forward and champion us. Certainly, even with pain meds, I am in no condition to do so.

Thank you.

Anonymous said...

I think a huge issue is proper patient screening - NOT limiting access to these medications that a doctor may deem to be of benefit, but proper patient screening. Also, as to Dr. Leavitt said, in so many ways, the war on these drugs being undertaken by various regulatory authorities is often based on flimsy studies of little evidentiary weight. And all of the media hype that this is the "new epidemic" is not helping. It reminds me of when the WHI came out in 2001 and everyone completely freaked out about hormone replacement therapy. It as "the" health news story of the moment. The amount spent on lawsuits because of that initial study is staggering. But since then, even the authors of the initial WHI study have gone back time and time again and backtracked on many of their initial findings or at least refined what the message of the study should be.

risaden said...

The thing is, people in chronic pain are often desperate, often do take more of their pain medication than they should, often take "a pill" from a buddy on a bad day, often don't drink for six months and then go out on their birthday and have 3 cocktails, may have undiagnosed sleep apnea, often believe they can use the same doses their body could tolerate safely a decade ago, often are taking opioids along with benzos (prescribed by two different doctors), and often have poor sleep, depressed mood, and suicidal thoughts. These folks are good people who are not using street drugs or using their own medications for anything other than to get out of pain. And unfortunately this combination of factors does lead to deaths. Most providers, like myself, are truly afraid that our patients will die, and we do everything we can think of to do to make sure that their regimens are safe. And yet, people die of unintentional overdoses anyway. Death is a part of medicine, but there is something that feels wrong when a patient dies (intentionally or unintentionally), using medication you have prescribed hoping to help.

SB. Leavitt, MA, PhD said...

Thank you, 'risaden,' for sharing your thoughts. Many other compassionate healthcare providers have expressed those same feelings of frustration and concern. Yet, allowing patients to suffer when there is medication that may help them -- whether opioids or other meds -- would be heartless torture.

Anonymous said...

I have tried but can not find any information on research into developing a devise to objectively measure pain levels in individuals. This could solve many problems related to pain and medication abuse.

As a retired social worker as well as a chronic pain suffer I have some insight into these issues.

Of the many suicidal clients I saw while working in mental health I can not remember even one person that really wanted to die, they just wanted a solution to their problem and since they could not find it they sought death. Chronic pain suffers are much the same they seek a solution to their pain problem and I nor any others I know about want to die. We want to be pain free or at least keep the pain to a tolerable level without side effects.
I know that often many seemingly unrelated events can be connected. In my opinion there are people with different motivations that could care less about people in pain or the number who die as long as they get what they want.

lindy19 said...

After reading this I wonder what the statistics would be if euthanasia were legal for anyone that had a condition that could not be treated.
I have seen it reported many times that apparent suicides were listed as accidental deaths because there was no note or threat of suicide.
People with strong pain that does not stop such as chronic pain patients maybe more likely to take a deliberate overdose or combine medications and alcohol and not tell anyone just to end things and people will think it was accidental. Also there is the consideration of insurance that will not be paid if it is a suicide so they make it look like an accident. Others maybe frightened into suicide if they are threatened with being put in a nursing home.
I have seen a few cases in the news of elderly couples where one kills their spouse and then kills themselves. Often they have no family who will care for them and they do not want to be apart.
I think all these statistics would change a lot if euthanasia were legal and not as difficult as it is in the Northwestern states where a person has to be within 6 months of death before they can use euthanasia.
Of course some are accidental as one person told me that had chronic pain and was getting a mild pain medicine from the veterans clinic so he took a lot of Tylenol in addition, but he did not know that a lot of Tylenol was in the VA medicine nor did he know that Tylenol has a bad effect on the liver. Luckily he saw a private doctor who discovered the problem and got him to change things. Otherwise he might have been an accidental death. lindy19