BY MIRIAM E. TUCKER
Elsevier Global Medical News
Overdose deaths involving opioid pain relievers now exceed deaths from heroin and cocaine combined, according to a report from the Centers for Disease Control and Prevention.
Prescription drug overdoses have been increasing in the United States over the last decade, and by 2008 had reached 36,450 deaths - almost as many as from motor vehicle crashes (39,973). Opioid pain reliever (OPR) sales have also increased, "despite numerous warnings and recommendations over the past decade for voluntary education of providers about more cautious use of OPR[s]," said Dr. Leonard J. Paulozzi and his associates at the CDC's division of unintentional injury prevention.
During 1999-2008, overdose death rates, sales, and substance abuse treatment admissions related to OPRs increased in parallel, with the overdose death rate in 2008 nearly four times the rate in 1999. Sales of OPRs in 2010 were four times those in 1999. The substance abuse treatment admission rate in 2009 was almost six times the rate in 1999. By 2010, enough OPRs were sold each year to medicate every American adult with 5 mg of hydrocodone every 4 hours for 1 month.
The report used death rates based on the National Vital Statistics System multiple cause of death files, age adjusted to the 2000 U.S. Census population. Deaths were attributed to drug overdose in 2008 at a rate of 11.9/100,000 population. Among those, a particular drug was specified for 74.5%. Of those 27,153 deaths, prescription drugs were a factor in 73.8%. And of those 20,044, OPRs were involved in 73.8% (14,800). Drug overdose death rates were 6.5/100,000 population for all prescription drugs and 4.8/100,000 for OPRs, compared with 2.8/100,000 for illicit drugs, including heroin, cocaine, hallucinogens, and stimulants (MMWR 2011;60:1-6).
Overdose resulted in 830,652 years of potential life lost, a number comparable to that of motor vehicle crashes. Overdose deaths varied fivefold by state, ranging from 5.5/100,000 population in Nebraska to 27.0/100,000 in New Mexico.
Middle-aged whites were more likely to die of an OPR overdose, compared with other races and age groups. Deaths rates involving OPRs among non-Hispanic whites and Native Americans/Alaska Natives were three times higher than the rates for blacks and Hispanic whites. Death rates from all categories of drug overdose were highest among people aged 35-54 years.
The investigators also looked at rates of nonmedical OPR use and annual drug sales, based on data from the 2008-2009 National Survey on Drug Use and Health and the Automation of Reports and Consolidated Orders System of the Drug Enforcement Administration. The prevalence of nonmedical use of OPRs during 2008-2009 ranged from 3.6% in Iowa and Nebraska to 8.1% in Oklahoma. The rate of OPR sales ranged from 3.7 kg/10,000 population in Illinois to 12.6 kg in Florida.
Differences in OPR overdose mortality by race and ethnicity can't explain the wide variation in death rates among states, nor can demographic differences fully explain the wide variations among states in the nonmedical use and sales of OPRs. Montana and Iowa, for example, both have largely non-Hispanic white populations. However, Montana's rate of nonmedical OPR use was 5.3% vs. Iowa's 3.6%, and Montana's OPR sales were 8.4 kg/10,000 population, compared with Iowa's 4.6 kg, Dr. Paulozzi and his associates noted.
In one study, 3% of physicians accounted for 62% of the OPRs prescribed, suggesting that the high-volume prescribers can have a major impact on the use of OPRs and overdose death rates. In Florida, the proliferation of illegitimate pain clinics - also called "pill mills" - appear to have contributed to increases in overdoses in that state.
"Public health interventions to reduce prescription drug overdose must strike a balance between reducing misuse and abuse and safeguarding legitimate access to treatment. To find this balance, health care providers should only use OPR[s] in carefully screened and monitored patients when non-OPR treatments have not been sufficient to treat pain, as recommended in evidence-based guidelines," the investigators wrote.