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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