The Epidemiology of Unintentional Drug Poisoning in the United States

1. The Epidemiology of Unintentional Drug Poisoning in the United States Len Paulozzi, MD, MPH SEOW Audio Conference December 12, 2007

2. Unintentional drug poisoning mortality rates, US, 1970-2004 Prescription drugs Crack cocaine Heroin

3. Methodology • Mortality counts are based on death certificate information only. • Coroners and medical examiners determine person’s intent and drug(s) responsible. • “Unintentional” poisoning deaths include “accidental” ingestion, overmedication, and overdoses of drugs used nonmedically (“drug overdoses”). • Unless otherwise indicated, suicides and deaths of undetermined intent are not included. • Most mortality statistics can be generated for single states using WISQARS or WONDER

4. Unintentional drug poisoning mortality rates by major drug type, US, 1990-1998

5. Unintentional drug poisoning mortality rates by major drug type, US, 1999-2004

6. Unintentional deaths from “narcotics” and “other/unspecified drug” by major type of drug, US, 1999-2004

7. Unintentional deaths from “narcotics” and “other/unspecified drugs” by type of opioid analgesic, US, 1999-2004

8. Unintentional drug poisoning mortality rates by sex and age group, US, 2003-2004

9. Unintentional poisoning mortality rates by race, US, 2004

10. 10.4 9.4 8.2 2.3 3.7 7.4 5.9 6.1 3.8 4.2 6.2 7.1 2.7 11.2 2.3 13.5 8.3 NH 7.9 7.2 7.4 13.5 VT 6.7 16.7 7.2 8.2 MA 9.3 6.0 6.6 7.9 11.6 RI 8.5 CT 8.5 8.3 11.0 NJ 5.9 11.4 11.9 DE 5.9 14.6 7.5 6.9 MD 10.7 5.4 6.6 DC 14.7 7.1 6.8 11.1 11.1 10.5 HI 7.2 Rate per 100,000 population 2.3-6.8 6.9-8.6 8.7-16.7 Unintentional and undetermined drug poisoning mortality rates by state, US, 2004

11. Age-adjusted rates of unintentional and undetermined drug poisoning mortality by urban-rural category and year, US, 1999--2004

12. Unintentional drug poisoning mortality rates and total sales of opioid analgesics in morphine equivalents by year in the U.S.

13. Sales of opioids by type, US, 1997 thru 3rd quarter, 2006(DEA ARCOS data)

14. Estimated numbers of new nonmedical users in past year by type of drug, US, 1990-2003 (NSDUH 2002-2004)

15. Prevalence of nonmedical use of prescription pain relievers in past year among persons aged 18 or older by education level, US, 2002-2004

16. Prevalence of nonmedical use and dependence/abuse of prescription pain relievers among persons aged 12 or older by period of use (NSDUH, 2005)

17. Epidemiology of opioid use versus opioid abuse • Although females are more likely to use opioids, males are more likely to abuse and overdose with them. • Although people over 65 are most likely to use opioids, people in 20s and 40s are most likely to abuse them. • Many people dying of prescription overdoses have a history of substance abuse. • Therefore, overdoses are more likely to represent abuse than overmedication.

18. Lessons learned • Regulated prescription drugs taken mostly by mouth can produce a larger overdose epidemic than illicit drugs of uncertain strength taken intravenously, such as heroin. • Just as a drug that is efficacious in clinical trials may not be effective in the community, drugs “safe” in terms of abuse in controlled settings may be abused in the community.

19. Some examples of how federal agencies are addressing the problem • CDC started surveillance using existing data and is supporting some etiologic and evaluation work. • FDA placed “black boxes” on OxyContin (2001) and methadone (2006). • DEA stepped up efforts against drug diversion. • DOJ provided funding for state prescription drug monitoring programs through the Hal Rogers Program since FY2002. • Congress passed the National All Schedules Prescription Electronic Reporting Act (NASPER) in 2005 to fund additional prescription monitoring programs. • White House Office of National Drug Control Policy issued a Synthetic Drug Control Strategy in May, 2006.

20. Thank you • Contact information: • Len Paulozzi, MD, MPH • Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, CDC • 770-488-1394 • lbp4@cdc.gov

21. Paulozzi LJ, Budnitz DS, Xi Y. Increasing deaths from opioid analgesics in the United States. Pharmacoepidemiology and Drug Safety 2006; 15:618-627. • Paulozzi LJ, Ballesteros MF, Stevens JA. Recent trends in mortality from unintentional injury in the United States. Journal of Safety Research 2006; 37:277-283. • Paulozzi LJ. Sharp rise in opioid analgesic involvement in drug abuse deaths in the American metropolitan areas. American Journal of Public Health 2006; 96:1755-1757. • Paulozzi LJ. Opioid analgesics and rates of fatal drug poisoning in the United States. American Journal of Preventive Medicine 2006; 31:506-511. • Kaplan J, Kraner J, Paulozzi LJ. Alcohol and other drug use among victims of motor-vehicle crashes -– West Virginia, 2004—2005. MMWR 2006;55:1293-1296. • Paulozzi LJ, Annest J. Unintentional poisoning deaths – United States, 1999-2004. MMWR 2007;56:93-96. • Paulozzi LJ. QuickStats: Percentage change in death rates for the leading causes of unintentional injury, by mechanism of injury --- United States, 1999—2004. MMWR 2007;56:309. • Paulozzi LJ, Annest J. US data show sharply rising drug-induced death rates. Injury Prevention 2007;13:130-132. • Paulozzi LJ. Overdoses are injuries too. Inj Prev 2007; 13:293-294. • Colliver, JD, et al. (2006) Misuse of prescription drugs: Data from the 2002, 2003, and 2004 National Surveys on Drug Use and Health (DHHS Pub. No. SMA 06-4192). • SAMHSA, National Survey of Drug Use and Health (2006) Results from the 2005 National Survey on Drug Use and Health: National Findings (OAS, NSDUH Series H-30, DHHS Pub. No. SMA 06-4194). Rockville, MD.