The number of people dying from an opioid overdose rose nearly 16% from 2014 to 2015, but the increase had little to do — at least directly — with prescription painkillers such as oxycodone or hydrocodone, the Centers for Disease Control and Prevention (CDC) reported last week.
Instead, the chief culprits behind the spike were heroin and illegally manufactured fentanyl (Table 1), according to an article published in the CDC’s Morbidity and Mortality Weekly Report (MMWR).
Roughly 52,000 people died from drug overdoses in 2015, up 11.4% from 2014. Of those deaths last year, 33,091 involved a legal or illegal opioid, a 15.5% increase over 2014.
Table 1. Heroin and Synthetic Opioids Besides Methadone Drive the Increase in Opioid Overdose Deaths
|Opioid Category||Overdose Deaths 2014 (Rate)1||Overdose Deaths2 2O15 (Rate)||% Change|
|Natural and semisynthetic opioids3||12,159 (3.8)||12,727 (3.9)||2.6%|
|Methadone4||3400 (1.1)||3301 (1.0)||-9.1|
|Synthetic opioids other than methadone5||5544 (1.8)||9580 (3.1)||72.2%|
|Heroin||10,574 (3.4)||12,989 (4.1)||20.6%|
Source: CDC Morbidity and Mortality Weekly Report, December 16, 2016.
1 Rates per 100,000 population.
2 Adding up the number of deaths by opioid category does not equal the total number of overdose deaths (33,091), because some deaths involved more than one opioid category.
3 Includes morphine, codeine, and semisynthetic prescription opioids such as oxycodone and hydrocodone.
4 Methadone is a synthetic opioid.
5 These synthetic opioids include tramadol and fentanyl.
Natural opioids such as morphine and semisynthetic opioids such as oxycodone figured into 12,272 deaths in 2015, a 2.6% increase over the year before. However, deaths involving synthetic opioids such as fentanyl and tramadol — but excluding methadone — shot up 72% during that period.
The CDC lays most of the likely blame for this trend on illegally manufactured fentanyl, often mixed with or sold as white heroin powder. An MMWR article reported that the number of drug products obtained by law enforcement that tested positive for fentanyl rose by 426% from 2013 to 2014.
The scourge of synthetic opioids is hitting some Northeast and Midwest states especially hard (Table 2).
Table 2. Overdose Deaths Involving Synthetic Opioids
Heroin was implicated in 12,989 fatal overdoses in 2015, a 20.6% increase over 2014. That toll represents almost 4 out of 10 opioid overdose deaths. South Carolina (57.1%), North Carolina (46.4%), and Maine (45.2%) posted the steepest increases in heroin deaths last year.
In contrast, the number of overdose deaths involving methadone fell from 3400 to 3301, or by 9.1%. The CDC attributes this decline in part to efforts by the US Food and Drug Administration to reduce the use of methadone for pain control through warnings, restrictions on high-dose formulations, and clinical guidance.
The CDC notes that some fatal overdoses were caused by opioids in more than one category. An example might be a combination of a synthetic opioid and a semisynthetic one.
Abuse of Prescription Opioids and Heroin “Intertwined”
Earlier this year, CDC Director Tom Frieden, MD, MPH, described the abuse of prescription opioids as a “doctor-driven epidemic.” That characterization has rung in some physicians’ ears as blame for the entire opioid crisis, including deaths from heroin and illegal fentanyl.
Of all fatal opioid overdoses in 2015, 38% involved natural and semisynthetic opioids normally prescribed by clinicians, but often diverted for illegal street sales. In last week’s MMWR article, the CDC stated that the 2.6% increase during 2015 in these overdose deaths “illustrates an ongoing problem with prescription opioids.” However, the rate of increase has slowed from 2013-2014, “potentially because of policy and health system changes, required prescription drug monitoring program review, legislative changes in naloxone distribution, and prescribing guidelines.”
Tightening up on prescription opioids will reduce the harm caused by heroin and fentanyl because the abuse of legal and illegal opioids is “intertwined,” the CDC said. “Non-medical use of prescription opioids is a significant risk factor for heroin use.”
Besides improving the prescribing habits of clinicians, the CDC recommends other cures for the opioid overdose epidemic:
- Improve access to, and the use of, prescription drug-monitoring programs, operating in every state except Missouri.
- Intensify efforts to distribute the overdose antidote naloxone.
- Expand treatment capacity for opioid-use disorder, including medication-assisted treatment such as naltrexone to manage addiction.
- Scale up programs supplying sterile needles and syringes to individuals who inject illegal opioids.