The opioid crisis is one of most shocking public health issues in the United States. Between 2001 and 2016 the number of opioid-related deaths more than tripled, with predictions that it could kill a further half million people by 2027.
There has been much speculation on the causes of the crisis. Initially there was a focus on apparent willingness of medical practitioners to freely prescribe opiates (Guy et al, 2018). While this remains a significant concern, attention has shifted to the increased availability of fentanyl and other synthetic opioids which are now held responsible for more deaths than prescribed opiates. The risk of premature death is heightened by multiple barriers to accessing drug treatment, particularly for those without access to medical insurance.
A recent study explores the burden of opioid-related mortality across the United States (Gomes et al, 2018). Burden is a public health concept used to refer to the number of lives lost as a result of a particular disease.
The study used data gathered from death certificates of US residents (Gomes et al, 2018). These were stored on a database which recorded the age and sex of the deceased, the primary cause of death and up to twenty additional causes. The authors focused on opioid-related deaths, defined as those with an underlying cause related to poisoning. They were interested in deaths attributable to prescribed opioids, as well as illicit opioids such as heroin and fentanyl derivatives. The data were used to calculate the proportion of deaths which could be attributed to opioids, as well as the number of years of life lost (YLL) using the World Health Organization’s standard life expectancy tables.
- Over the fifteen year study period, the number of opioid-related deaths rose sharply, from 33.3 deaths to 130.7 deaths per million population
- By the end of the study period, 1 in 65 deaths were opioid-related compared with 1 in 255 at the outset
- The burden of opioid-related mortality falls disproportionately on men. By 2016, they accounted for approximately two-thirds of opiate-related deaths
- In 2016, the median age of death due to opioid poisoning was 40. There were statistically significant increases across all age groups during the study period with the largest absolute increases among those aged 25-34, followed by those aged 15-24
- Whilst the proportion of opiate-related deaths was lower among the older age groups (55-64 years and 65 years and older) and absolute numbers were small, the number among those aged 55-64 increased six-fold
- In 2016, approximately 1.68 million person-years of life were lost due to opioid use. The burden was highest among adults aged between 25-44. In 2016 the YLL from opioid-related death exceeded that attributable to hypertension, HIV/AIDS and pneumonia and amounted to one-tenth of those associated with cancer.
The study brings into sharp relief the potential risks associated with prescribed and non-prescribed opiate use, particularly for men aged 25-34. The authors concluded that:
Premature death from opioids imposes an enormous and growing public health burden across the United States.
Strengths and limitations
The study has a number of strengths. First, it attempts to measure the public health impact of the US opioid crisis. The number of deaths are shocking in their own right but quantifying the number of years lost due to premature death illustrates vividly the magnitude of the opioid crisis. Second, it draws attention to those most at risk of opioid-related mortality. Finally, given that the rapid rise in opioid-related deaths is not peculiar to the US, the authors offer a methodological approach which can be replicated in other countries.
As the authors acknowledge, there are important questions to ask about the validity and reliability of the data. Death data are the outcome of sometimes lengthy processes which rely upon professional judgement about the likely cause of death and the most appropriate way to record them. This may be difficult to ascertain for opioid users due to the existing health problems for which pain relief has been prescribed or due to the multiple health problems typically experienced by illicit opiate users (Schulte et al, 2014). Furthermore, the authors had to exclude cases for which age was not recorded. They concluded that the burden of opioid-related mortality they calculated is likely to be lower than the true burden in the United States.
The study made use of an existing database which only recorded the age and sex of the deceased person. As a result, the authors cannot explore whether the burden of opioid-related mortality was experienced differentially in any more detail. Other studies suggest that race/ethnicity is significant with higher rates of drug-related mortality among the White population in comparison with Black and Hispanic populations. Similarly, socio-economic factors are likely to be influential. A recent study in Orange County, California revealed that being homeless was a significant risk factor for opioid-related death (Marshall et al, 2018).
Implications for practice
Gomes et al. (2018) argue that their findings support the need for targeted efforts at high-risk populations. They propose a two-pronged approach: the need for appropriate prescribing alongside harm reduction measures, although little detail is provided on how these policy implications might be translated into practice. The accompanying editorial (Samet and Kertesz, 2018), which also reports on the findings of a study of those using opioids to manage chronic pain (Hwang et al, 2018) makes some specific policy recommendations. They argue for immediate access to effective clinical engagement comprising of evidence-based medication treatment (particularly substitute prescribing), coupled with additional recovery support including psychological therapies, housing and help to return to work. Samet and Kertesz (2018) make an important point that alongside additional resources, this requires treating addiction as a ‘mainstream health concern’ (p.2) so that health professionals are routinely trained in how to respond to it so they can work in collaboration with addiction specialists. There is a case too for extending this training to those whose work routinely brings them into contact with opioid users; for example, criminal justice practitioners or those working with homeless populations.
Neither Gomes et al (2018) nor Samet and Kertesz (2018) consider the strategies which are now routinely proffered as effective strategies to reduce the number of drug-related deaths. Surprisingly there is no reference to the use of naloxone which is widely available in the US. Lack of reference to heroin-assisted treatment and drug consumption rooms is less surprising given that they remain controversial measures in the US, despite being well-established and regarded as effective in other countries (ACMD, 2016).
The findings of the study strengthen the case for targeting resources on ‘at-risk’ groups. When resources are scarce, this is an attractive option but there are dangers attached to this approach, as it runs the risk of neglecting the groups which may be a cause for concern. Gomes et al (2018) make a strong case for targeting those aged 55-64 due to the rapid increase in opioid-related deaths among this group. In the drugs field, women frequently experience a Cinderella service with provision driven by the needs of the (male) majority which overlooks their distinct needs. The case for a gender-specific approach to drug-related mortality has been powerfully made in a recent report on Scotland where deaths among women are rising at a faster rates than men’s. Quantifying the public health burden of the opioid crisis is important, but care must be taken not to heighten the risk of opioid-related mortality for groups who may be viewed as too few to count.
Conflicts of interest
Nothing to report
Gomes T, Tadrous M, Mamdani MM, Paterson JM, Juurlink DN. (2018) The Burden of Opioid-Related Mortality in the United States. JAMA Network Open. 2018;1(2):e180217. doi:10.1001/jamanetworkopen.2018.0217
Guy GP, Shults RA. (2018) Opioid Prescribing in the United States. American Journal of Nursing: February 2018 – Volume 118 – Issue 2 – p 19–20 doi: 10.1097/01.NAJ.0000530238.99144.e8
Schulte MT, Hser YI. (2014) Substance Use and Associated Health Conditions throughout the Lifespan. Public Health Rev. 2014;35(2).
Marshall JR, Gassner SF, Anderson CL, Cooper RJ, Lotfipour S, Chakravarthy B. (2018) Socioeconomic and geographical disparities in prescription and illicit opioid-related overdose deaths in Orange County, California, from 2010-2014. Subst Abus. 2018 Feb 21:1-7. doi: 10.1080/08897077.2018.1442899. [PubMed abstract]
Samet JH, Kertesz SG. (2018) Suggested Paths to Fixing the Opioid Crisis: Directions and Misdirections. JAMA Network Open. 2018;1(2):e180218. doi:10.1001/jamanetworkopen.2018.0218
Hwang CS, Kang EM, Ding Y, et al. (2018) Patterns of immediate-release and extended-release opioid analgesic use in the management of chronic pain, 2003-2014. JAMA Netw Open. 2018;1(2):e180216. doi:10.1001/jamanetworkopen.2018.0216
ACMD (2016) Reducing Opioid-Related Deaths in the UK (PDF). Advisory Council on the Misuse of Drugs, Dec 2016.
surely targetting resources at people already using is too late; we need to prevent the initial situations and beliefs that initiate the use?