Opioid Overdose Statistics: As Clear as Mud

By Pat Anson, Editor

We’ve written before about how confusing and muddied the statistics can be for overdose deaths from opioid pain medication. (see “Lies, Damned Lies, and Overdose Statistics”). Now the White House and the Centers for Disease Control and Prevention are adding to the confusion.

Last week a news release from the White House Office of National Drug Control Policy stated that 17,536 Americans died in 2015 from overdoses involving prescription opioids, a 4% increase from the year before.

This week the CDC reported in its Morbidity and Mortality Weekly Report that the number of overdoses involving painkillers was actually smaller.

“Natural opioids (including morphine and codeine) and semi-synthetic opioids (including commonly prescribed pain medications such as oxycodone and hydrocodone) were involved in more than 12,700 deaths in 2015,” a CDC news release said. The agency said that was a 2.6% increase from the year before.

We asked the CDC to explain the discrepancy and were given a third number

“Given the recent surge in illegally-made fentanyl, the CDC Injury Center is analyzing synthetic opioids (other than methadone) separately from other prescription opioids (natural, semi-synthetic, and methadone). Using this approach, the number of deaths involving prescription opioids was… 15,281 in 2015,” CDC spokesperson Courtney Leland said in an email.

“This number better reflects the deaths associated with prescription opioids given the changing nature of the epidemic and increasing surge of illicit opioids.”

And what about the White House estimate?

“Their analysis of 17,536 deaths in 2015 was calculated by including any death that involved: opium; natural and semi-synthetic opioids; methadone; and unspecified narcotics (opioids). You would need to check with them about their rationale/methodology,” Leland explained.

In other words, the White House Office of National Drug Control Policy knowingly counted a number of overdoses caused by illicit opioids as prescription drug deaths.

All of these numbers may make your eyes glaze over, but they demonstrate an important point about the nation’s so-called opioid epidemic: No one really knows how bad it is.  Which is startling, because it’s an important national issue and Congress just voted to spend another $1 billion to fight it.

They may want to get their numbers straight first.

One thing the White House and the CDC do agree on is that overdoses from illegal opioids such as heroin and fentanyl are soaring, and deaths involving opioid pain medication appear to be leveling off.

The CDC reported many troubling statistics about opioid overdoses, which claimed over 33,000 lives last year:  

  • Death rates nationwide from synthetic opioids such as fentanyl increased by over 72%
  • Death rates from synthetic opioids more than doubled in New York (136%), Connecticut (126%) and Illinois (120%).
  • Heroin death rates nationwide increased by nearly 21%
  • Deaths rates from heroin jumped even more in South Carolina (57%), North Carolina (46%), and Tennessee (44%).

Perhaps the only bright spot was that deaths associated with methadone dropped by 9 percent, which the CDC attributed to lower methadone doses and less prescribing.

The agency still believes there is an “ongoing problem with prescription opioids” and that the number of overdoses may be undercounted.  

“Regardless of the analysis strategy used, prescription opioids continue to be involved in more overdose deaths than any other drug, and all the numbers are likely to underestimate the true burden given the large proportion of overdose deaths where the type of drug is not listed on the death certificate,” the CDC explains in a separate report.

Questionable Data

The CDC continues to rely on death certificate codes for much of its data, which many experts find troubling because the codes do not reflect the cause of death --- only the conditions that exist at the time of death.  In other words, somebody could die from lung cancer, but if a doctor used morphine to help ease the dying patient’s cancer pain, a box could be checked on their death certificate indicating opioids were present at the time of death. The CDC would consider that an “opioid involved” death.

Other factors that raise questions about the reliability of the CDC’s data:

  • Overdose deaths were based on data from only 28 states “with high quality reporting”
  • Wide variability in the expertise and training of local medical examiners and coroners who complete death certificates
  • Nearly 1 out of 5 death certificates nationwide do not include any drug data
  • Some heroin deaths may have been misclassified as prescription drug deaths
  • Some overdose deaths may have been counted twice.

Critics also say there is a disturbing tendency by the CDC to “cherry pick” data to dramatize the harm caused by prescription opioids, without ever discussing their benefits. For example, the agency referred to a recent report from the DEA this way:

“The Drug Enforcement Administration referred to prescription drugs, heroin, and fentanyl as the most significant drug-related threats to the United States. The misuse of prescription opioids is intertwined with that of illicit opioids; data have demonstrated that nonmedical use of prescription opioids is a significant risk factor for heroin use, underscoring the need for continued prevention efforts around prescription opioids.”

The CDC does not mention that the DEA also found that the prescribing and abuse of opioid pain medication is actually in decline, that the number of admissions to treatment centers for painkiller addiction is falling, and that less than 1% of prescription opioids are diverted. Nor does the CDC mention that the DEA found a “massive surge” in the production of counterfeit pain medication made with illicit fentanyl, which is probably killing quite a few patients seeking pain relief.  

The CDC cites its own research to make the claim that it “did not find evidence that efforts to reduce opioid prescribing were leading to heroin overdoses.” But the DEA report said just the opposite: Some prescription opioid users are switching to heroin when they are no longer able to obtain medication:

“Some abusers, when unable to obtain or afford CPDs (controlled prescription drugs), begin using heroin, a cheaper alternative that offers similar physiological effects. With the successful reduction in availability of controlled prescription drugs, more users may shift to abusing heroin.”

This isn’t the first time the CDC has been accused of cherry picking data for public consumption. The same complaint arose when the agency released its opioid prescribing guidelines, many of which relied on “weak” or “very weak” evidence to support the contention that opioids should not be prescribed for chronic pain.

Recent research published in the journal Pain Medicine also took the agency to task for dismissing evidence that opioids could be used safely long term, while making no mention of the significant risks posed by non-opioid pain medication.

No common nonopioid treatment for chronic pain has been studied in aggregate over longer intervals of active treatment than opioids. To dismiss trials as ‘inadequate’ if their observation period is a year or less is inconsistent with current regulatory standards,” wrote lead author Daniel Carr, MD, President of the American Academy of Pain Medicine and Program Director of Pain, Research, Education & Policy at Tufts University School of Medicine.  

“Basing therapeutic decision-making upon durations of published clinical efficacy or effectiveness trials does not support choosing any drug or nondrug therapy over another. In fact, the opening words of the first recommendation of the CDC… make no mention of the overwhelmingly strong evidence for significant morbidity and mortality risk from the most likely nonopioid alternatives to opioid therapy for chronic pain: NSAIDs, coxibs (cox-2 inhibitors), and acetaminophen.”

Although the CDC guidelines are “voluntary” and only intended for primary care physicians, many patients have reported that their chronic pain is going untreated or under-treated because they are no longer able to obtain opioids or their doses have been drastically lowered by their physicians. Other patients have been abruptly “fired” by doctors who no longer want to treat chronic pain because they fear prosecution for overprescribing opioids. Still other patients are contemplating or have committed suicide.

Where are the statistics about that?