U.S. Opioid Painkiller Overdose Deaths on the Rise

ATLANTA, July 24 -- Opioid-based prescription painkillers have surpassed cocaine and heroin as the cause of accidental drug overdose deaths in the United States, according to a team of CDC researchers.

However, it is unclear how many of the deaths were among individuals with legitimate prescriptions and pain-relief needs compared with recreational drug users or addicts who obtained the painkillers illegally, said Leonard J. Paulozzi, M.D., M.P.H., of the CDC's National Center for Injury Prevention and Control here.

Opioid painkillers were listed as the sole cause of overdose for 4,451 deaths in 2002, more deaths than from cocaine (2,569) and heroin (1,061) combined, Dr. Paulozzi and colleagues reported online today in the journal Pharmacoepidemiology and Drug Safety.

Opioid painkillers in the study included semi-synthetic derivatives of opium, such as oxycodone and hydrocodone, as well as fully synthetic opioid agonists such as fentanyl and methadone. All of these drugs are sold under a wide variety of brand names.

The study compared National Center for Health Statistics data on drug overdoses before opioid painkillers became commonly prescribed (from 1979 to 1990) and afterward (from 1990 to 2002). Key findings include:

• Deaths from all types of unintentional drug overdoses increased 5.3% per year on average from 1979 to 1990 and by 18.1% per year from 1990 to 2002.
• Between 1999 and 2002, the number of opioid analgesic overdoses on death certificates increased 91.2%, while overdose deaths attributed to heroin increased by 12.4% and those attributed to cocaine rose by 22.8%.
• Among opioid analgesic overdoses in 2002, 54% were from semi-synthetic opioids such as oxycodone and hydrocodone, 32% were from methadone, and 13% were from other synthetic opioids such as fentanyl.

"The increase in drug poisoning since 1990 coincides with a dramatic increase in the prescription of major types of opioid analgesics, as physicians were encouraged to prescribe stronger analgesics (i.e., opioids) for pain management," the CDC investigators said.

"Worldwide consumption of morphine, hydrocodone, oxycodone, fentanyl, and methadone, most of which is accounted for by the United States, increased at least fourfold from 1990 to 2002," they said.

However, "evidence also suggests that at least some of these deaths are related to intentional abuse of drugs-not to therapeutic dosing errors among those suffering chronic pain," they added.

For example, medical examiners in states with epidemics of opioid overdoses have found that most victims had a history of substance abuse and did not have a prescription for the medication, they said.

Although the study highlighted an association, it did not establish a causal connection between the increase in prescriptions for and the increase in overdose deaths from opioid painkillers, said David E. Joransen, M.S.S.W., and Aaron M. Gilson, Ph.D., of the University of Wisconsin-Madison, in a commentary.

Further evidence that the increase in overdose deaths may be related to illegal use of opioid painkillers is that up to 6 million doses of these drugs were stolen from U.S. pharmacies in 2003 alone, according to data from the Drug Enforcement Agency, the commentators said.

"Unwittingly, publicity about simple associations can exacerbate fears of appropriate medical use of prescription drugs among pain patients and the public, trigger more drug control, and increase fears of regulatory scrutiny among legitimate prescribers and dispensers. All of these can lead to further under-treatment of pain," they warned.

The authors concluded that "the overall goal should be to identify ways to reduce deaths from opioid analgesics without diminishing the quality of care for patients with a legitimate need for pain management."