What would it really take to solve the overdose epidemic in the United States?

The high overdose mortality rates in the United States poses several questions: Why have they been increasing exponentially since 1979? Why are they so high? And how can they be greatly reduced? Building on past research, the causes of the increase seem to be deeply rooted in US social and economic structures and processes, rather than due only to opioid prescription patterns or the advent of synthetic opioids. Given this, we consider what changes might be needed to reverse the exponentially-increasing overdose mortality. We use a path dependency argument to argue that the United States political, economic, and public health systems have helped create this crisis and, unfortunately, continue to heighten it. These same systems suggest that proposals to expand harm reduction and drug treatment capacity, to decriminalize or legalize drugs, or to re-industrialize the country sufficiently to reduce "communities of despair" will not be enacted at a scale sufficient to end the overdose crisis. We thus suggest that in the United States serious improvements in overdose rates and related policies and structures require massive social movements with a broad social change agenda.

Racial, Ethnic, and Regional Disparities in Cocaine-Involved Overdose Deaths in the US, 1999-2020

BACKGROUND

Social inequalities among underrepresented communities may lead to higher overdose mortality involving cocaine use. We assessed the temporal trends in cocaine-involved overdose mortality rate in the US by race, ethnicity, and geographic region from 1999 to 2020.

METHODS

We conducted a cross-sectional study among adults in the US using data from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database (1999 to 2020). To identify cocaine-involved overdose decedents, we used the International Classification of Diseases Code, 10th Revision-T40.5. We used Joinpoint regression to examine the trends in age-adjusted cocaine-involved overdose mortality rates (AAMR) by race, ethnicity, and geographic region and estimated annual percentage changes (APC).

RESULTS

Overall, cocaine-involved overdose mortality trends increased (APC, 11.3%; 95% CI, 0.6, 23.2) from 2017 to 2020. The latest trends have remained stable among Non-Hispanic Whites since 2017 (APC, 4.3%; 95% CI, -5.7%, 15.4%) but have significantly increased among Non-Hispanic Blacks (APC, 27.2%; 95% CI, 22.1%, 32.5%), Hispanics (APC, 26.9%; 95% CI, 20.6%, 33.5%), and American Indians/Alaska Natives (APC, 24.1%; 95% CI, 16.5%, 32.2%).

CONCLUSION

Cocaine-related overdose deaths in the US significantly increased between 2017 and 2020, but the increase was among racial and ethnic minorities and not among Non-Hispanic Whites. These findings suggest a need to address the US' longstanding racial and ethnic healthcare inequities.

U.S. state policies on opioid prescribing during the peak of the prescription opioid crisis: Associations with opioid overdose mortality

BACKGROUND

In response to the opioid overdose crisis in the United States, many states implemented policies to guide opioid prescribing, but their impact on overdose mortality (prescription and non-prescription) remains poorly understood. We examined the impact of U.S. state opioid-prescribing policies on opioid overdose mortality following implementation.

METHODS

We calculated opioid overdose mortality rates from 1999-2016 by U.S. state using the CDC WONDER database, overall and separately for overdose deaths from prescription and non-prescription opioids. For each state, policies active on 1/1/2014 were reviewed for the presence and strength of six provisions recommending judicious opioid prescribing practices; "strong" provisions used the words "should," "shall," or "must". Interrupted time series (ITS) tested the association of each strong provision with overdose mortality, overall and separately for prescription and non-prescription opioids, in the two years following implementation. Sensitivity analyses compared between states, used time-lagged analyses, and excluded synthetic opioids from non-prescription opioid deaths.

RESULTS

All six provisions had consistent direction of effect in ITS and sensitivity analyses. Strong provisions for prescriber training and limits on opioid dose reduced the slope of overall and prescription opioid overdose mortality in both ITS and sensitivity analyses. Reduced non-prescription opioid overdose mortality was only associated with strong provision for prescriber training. Some provisions had a negative impact. In ITS, strong provision for prescriber response to misuse increased the slope of non-prescription opioid overdose mortality. Strong provision for mandatory prescription drug monitoring program use had no relationship with overdose mortality in ITS and was associated with increased overall, prescription and non-prescription opioid overdose mortality in between-state sensitivity analysis.

CONCLUSION

Opioid prescribing policies in U.S. states at the peak of the prescription opioid epidemic had modest mortality benefit, and did not reduce non-prescription opioid overdose mortality. A strong provision for prescriber training was the only provision associated with reduced prescription and non-prescription opioid overdose mortality. These findings can inform future efforts addressing prescription drug epidemics.

Risks and overdose responses: Participant characteristics from the first seven years of a national take-home naloxone program

BACKGROUND

In 2014, the Norwegian government funded a large-scale take-home naloxone (THN) program to address high overdose mortality rates. The aims of this study are to describe characteristics among persons trained to receive THN, describe actions taken following THN use at an overdose event and to explore factors associated with naloxone use.

METHODS

This was a prospective cohort study of individuals who received THN from 2014 to 2021. Descriptive characteristics were collected at initial training. When returning for refill, participants reported on their previous naloxone use. In a multivariable logistic regression model exploring associations with naloxone use: gender, age, opioid use history, concomitant drug use, injecting, history of experienced or witnessed overdose were included.

RESULTS

In total, 3527 individuals were included in this study. There were 958 individuals who returned for refills 2303 times. Most participants were male (63.6%), with a history of opioid use (77.5%). Those who reported naloxone use were more likely to have a history of opioid use (aOR= 4.1; 95% CI=2.77,6.1), were younger (aOR=0.98; 95% CI=0.97,0.99) and had witnessed overdoses (aOR=3.3; 95% CI=1.98,5.34). Among current opioid users, the odds were higher for injectors (aOR=1.57; 95% CI=1.18,2.1). Naloxone use was reported 1282 times. Additional actions such as waking the person and calling the ambulance were frequently reported. Survival was reported in almost all cases (94%).

CONCLUSION

People who use drugs are a suitable target group for THN-programs, as they seem to be willing and capable to reverse overdoses effectively. Given their personal risk factors for overdosing, recipients will likely also benefit from overdose prevention education.

The spatial prevalence and associated factors of opioid overdose mortality in Milwaukee County, Wisconsin (2003-2018)

Mortality from opioid overdose has become the leading cause of non-natural death in Milwaukee County, Wisconsin in recent years. In order to better understand the opioid epidemic and formulate pro-active responses to the crisis at the local level, this study examines the spatial prevalence and associated factors of opioid overdoses that end in mortality in Milwaukee, WI using the spatial econometrics model. The social determinants of health framework is used to identify the potential related socioeconomic factors associated with opioid use and misuse. Using principal component analysis, 6 primary components are identified from the chosen social determinants and used as explanatory variables in the spatial econometric analysis. The age-adjusted standardized mortality rate is calculated for each census tract as the dependent variable in the analysis. Overall low socioeconomic status, labor-intensive occupations, income inequality, and the 20-34-year-old age group are identified as variables with a significant contribution to high overdose mortality rates, both directly and indirectly. A significant global spillover effect is also identified at the census tract level, indicating the severity of the opioid epidemic in Milwaukee County. This study reveals the overall contribution that socioeconomic factors have on the opioid epidemic and their associated feedback effects, providing targeted information on the opioid epidemic.

Naloxone administration among opioid-involved overdose deaths in 38 United States jurisdictions in the State Unintentional Drug Overdose Reporting System, 2019

BACKGROUND

The majority of drug overdose deaths in the United States involve opioids, and synthetic opioid-involved overdose death rates are increasing. Naloxone is a key prevention strategy yet estimates of its administration are limited.

METHODS

We analyzed 2019 data from 37 states and the District of Columbia in CDC's State Unintentional Drug Overdose Reporting System to estimate the percentage of decedents, by sociodemographic subgroup, who experienced a fatal opioid-involved overdose and had no evidence of naloxone administration.

RESULTS

A total of 77.3% of 33,084 opioid-involved overdose deaths had no evidence of naloxone administration. Statistically significant subgroup differences were observed for all sociodemographic groups examined except housing status. The highest percentages of decedents lacking evidence of naloxone administration were those with highest educational attainment (doctorate or professional degree, 87.0%), oldest (55-64 years, 83.4%; ≥65 years, 87.3%) and youngest ages (<15 years, 87.5%), and single marital status (84.5%). The lowest percentages of no evidence of naloxone administration were observed for non-Hispanic American Indian/Alaskan Native persons (66.2%) and those ages 15-24 years (70.8%).

CONCLUSIONS

More than three-quarters of opioid-involved overdose deaths had no evidence of naloxone administration, underscoring the need to ensure sufficient naloxone access and capacity for utilization. While fatal overdose data cannot fully characterize sociodemographic disparities in naloxone administration, naloxone education and access efforts can be informed by apparent inequities. Public health partners can assist persons who use drugs (PWUD) by maintaining naloxone supply and amplifying messages about the high risk of using drugs alone among PWUD and their social networks.

Medicaid expansion and drug overdose mortality during the COVID-19 pandemic in the United States

BACKGROUND

The COVID-19 pandemic caused disruptions in the delivery of health services, which may have adversely affected access to substance use disorder (SUD) treatment services. Medicaid expansion has been previously associated with increased access to SUD services for low-income adults. Thus, the pandemic may have differentially impacted overdose mortality depending on expansion status. This study examined trends in overdose mortality nationally and by state Medicaid expansion status from 2013 to 2020.

METHODS

State-level data on overdose mortality were obtained from the Centers for Disease Control and Prevention's WONDER database for 2013-2020 (N = 408 state-years). The primary outcomes were drug and opioid overdose deaths per 100,000 residents. The primary exposure was Medicaid expansion status as of January 1st, 2020. Difference-in-difference (DID) models were used to compare changes in outcomes between expansion and non-expansion states after the onset of the COVID-19 pandemic.

RESULTS

The U.S. experienced 91,799 drug overdose deaths in 2020, a 29.9% relative increase from 2019. Expansion states experienced an adjusted increase of 7.0 drug overdose deaths per 100,000 residents (95% CI 3.3, 10.7) and non-expansion states experienced an increase of 4.3 deaths (95% CI 1.5, 8.2) from 2019 to 2020. Similar trends were observed in opioid overdose deaths. In DID models, Medicaid expansion was not associated with changes in drug (0.9 deaths, 95% CI -2.0, 3.7) or opioid overdose deaths (0.8 deaths, 95% CI -1.8, 3.5).

CONCLUSIONS

The increase in drug or opioid overdose deaths experienced during the first year of the COVID-19 pandemic was similar in states with and without Medicaid expansion.

Toxicological and pharmacologic sex differences in unintentional or undetermined opioid overdose death

INTRO

Understanding sex differences in toxicological etiologies of opioid-related drug overdose death could inform future sex- and gender-specific approaches to prevention and treatment.

METHODS

A retrospective review of accidental or undetermined opioid-involved overdose deaths in Rhode Island 2016-2019 was performed using the Rhode Island Department of Health State Unintentional Drug Overdose Reporting System (SUDORS) database. Decedent toxicology data was linked with state Prescription Drug Monitoring Program (PDMP) records.

RESULTS

Of 766 cases in the analytical sample, 568 cases were in men (74.2%) and 198 cases were in women (25.6%). Median age was 40.0 years for males and 42.0 years for females. Statistically significant sex-differences in drug exposures were found. Compared to men, women were more likely have exposure to benzodiazepine, antipsychotic, and antidepressant drug classes and less likely to have fentanyl and alcohol co-exposure. No sex differences were found in cocaine and amphetamine exposure. Female decedents were more likely than male decedents to have a prescription for benzodiazepines or opioids in the 30 days before death (40% vs 21%). The proportion of decedents with a benzodiazepine on post-mortem toxicology testing in combination with a benzodiazepine prescription (p < 0.001) or an opioid prescription (p = 0.005) was over two times higher in women than men.

CONCLUSION

Higher rates of controlled substance prescription prior to death and prescription drug co-exposures suggest that female opioid-involved drug overdose decedents are often in contact with the health care system immediately preceding their death, presenting the opportunity to create patient-centric approaches for prevention, harm reduction, and substance use treatment.

Overdose deaths involving psychostimulants with abuse potential, excluding cocaine: State-level differences and the role of opioids

BACKGROUND

Over the course of the past decade, psychostimulants such as methamphetamines have been increasingly reported in overdose deaths in the United States (US). Methamphetamine use has recently risen among individuals who use opioids, yet it is unclear what role the opioid crisis has played in the increase in psychostimulant-involved overdose mortality in states across the US.

METHODS

Mortality data from the Centers for Disease Control and Prevention were used to examine recent state-level changes in overdose deaths involving psychostimulants with abuse potential, excluding cocaine. Psychostimulant-involved overdose mortality rates, changes in rates, and opioid co-involvement were compared by state and plotted on choropleth maps. Ordinary least squares regression analyses were used to test the associations between a state's psychostimulant-involved overdose mortality rate change and several state-level indicators related to the opioid crisis.

RESULTS

From 2015/2016-2017/2018, significant increases in psychostimulant-involved overdose mortality rates were observed in 42 of 47 states with data available. Each of the three state-level indicators examined in the study (opioid prescribing rate in 2012, past-year prevalence of opioid use disorder from 2015-2018, and increase in drug overdose mortality during the earliest stages of the opioid crisis from 1999-2012) was positively associated with the absolute rate change in psychostimulant-involved overdose mortality from 2015/2016-2017/2018.

CONCLUSIONS

Although deaths involving methamphetamine have historically been primarily concentrated in the western US, results of the study reflect the alarming increase in psychostimulant-involved overdose mortality across the nation, especially in some of the states heavily impacted by the opioid crisis.

Cocaine use and overdose mortality in the United States: Evidence from two national data sources, 2002-2018

BACKGROUND

Cocaine-involved overdose mortality has recently risen in the United States (US), yet it is unclear to what extent patterns in cocaine-involved overdose mortality parallel patterns in cocaine use. This study: examined time trends (2002-2018) in past-year cocaine use and cocaine-involved overdose mortality in the US; and compared demographics and drug involvement of adults who reported past-year cocaine use versus adults who died of a cocaine-involved overdose.

METHODS

Data from two sources were utilized: (1) the National Survey on Drug Use and Health (n = 1,334 adults self-reporting cocaine use in 2018); and (2) the Multiple Cause of Death dataset of the National Center for Health Statistics (N = 14,630 adults who died of a cocaine-involved overdose in 2018). The study examined prevalence of past-year cocaine use, mortality rates for cocaine-involved overdose, 2002-2018 trends, demographic characteristics, and involvement of other drugs.

RESULTS

Results of Joinpoint Regression indicated that the prevalence of past-year cocaine use increased after 2011, with an annual percent change of 5.13, while age-adjusted cocaine-involved overdose mortality rates escalated after 2012, with an annual percent change of 26.54. In 2018, prevalence of past-year cocaine use did not significantly differ (p = 0.09) by racial/ethnic group, yet Non-Hispanic Blacks had an age-adjusted cocaine-involved overdose mortality rate more than double the rate in Non-Hispanic Whites and significantly higher (p < 0.001) than in any other group.

CONCLUSIONS

While the prevalence of cocaine use has increased modestly, cocaine-involved overdose mortality has risen dramatically. Cocaine-involved overdose mortality is disproportionately affecting individuals who are Black, older, or with lower educational attainment.

Bowling alone, dying together: The role of social capital in mitigating the drug overdose epidemic in the United States

BACKGROUND

Drug overdose deaths have risen precipitously over the last fifteen years. Substantial geographic variation, beyond a simple rural-urban dichotomy, exists in the concentration of overdose deaths, suggesting the existence of as-yet unidentified environmental variables that predict resilience (or vulnerability) to drug overdoses. Motivated by reports highlighting the role of community fragility in the opioid epidemic, we explore whether social capital attenuates overdose death rates.

METHODS

We conducted an ecologic temporal trends study from 1999 to 2014 to investigate the association between mortality due to drug overdose and social capital. Data from multiple sources were compiled at the county-level to produce an analytic dataset comprising overdose mortality, social capital, and a host of potentially confounding variables indicated by the literature (N=49,664 county-years). Multinomial logistic regression was used to estimate the likelihood that a county falls in low (<4 deaths per 100,000), moderate, or high (>16 deaths per 100,000) categories of annual overdose morality.

RESULTS

We observed a strong and statistically significant inverse association between county-level social capital and age-adjusted mortality due to drug overdose (p<0.01). Compared to the lowest quintile of social capital, counties at the highest quintile were 83% less likely to fall in the "high-overdose" category and 75% less likely to fall in the "moderate-overdose" category.

CONCLUSION

This study finds large-sample evidence that social capital protects communities against drug overdose. This finding could help guide policymakers in identifying where overdose epidemics are likely to occur and how to ameliorate them.