The CDC just recently released the 2015 mortality data, so I
thought it would be good to do an update of some previous posts that used the
data through 2014. (See here and here and here for example; several other posts of mine from 2016 include this data.)
There were 52,623 drug poisoning deaths in 2015, which is up
from 47,196 in 2014. But these are raw totals and aren’t very meaningful. They
include accidental deaths, suicides, “undetermined intent”, and murder, and the
CDC has separate codes for each of these. I don’t think it’s quite fair to add
in suicides if we’re talking about “the drug problem,” because accidentally
overdosing is very different from willfully ending your own life. These are
different social problems, and the only reason to include suicides in the total
is that you’re trying to inflate the number to make it look scarier. If we’re
just looking at accidental drug poisonings, there were 44,335 in 2015 (up from
38,841 in 2014). (Accidental deaths are codes X40-X44, suicides are codes
X60-X64, “undetermined intent” are codes Y10-Y14, and murder is X85, in the
ICD10 coding system. Murdering someone with drugs is apparently rare; there are
only 94 cases of it in 2015.)
I suspect you will see a lot of news stories starting with
“There were 52,600 drug overdoses in 2015…” If you see such a story, scan it to
see if it gives a breakdown by “accidental vs intentional.” If it doesn’t,
that’s a big warning sign that the author didn’t do their homework. Or perhaps the author is
trying to sell you a narrative using inflated and irrelevant numbers. Read such
pieces carefully. If the piece starts with the 52k figure then shifts to
talking about the “opioid epidemic,” the author has done a bait-and-switch. The
relevant figure there is more like 15,000 to 19,000, depending on exactly how you count them.
Here are the notable things that happened between 2014 and
2015. Heroin deaths climbed from 10,754 deaths in 2014 to 13,069 deaths in 2015,
taking the top spot. Other Opioids rose a little, from 12,657 to 12,927 deaths.
Cocaine, which had been declining from 2006 to 2013, rose over the last two
years (at 5495 deaths in 2013, 5992 deaths in 2014, and 6945 deaths in 2015).
Other synthetic narcotics (which includes fentanyl and other very powerful
synthetic opioids that are often a thousand times as potent as morphine) rose
from 5695 deaths in 2014 to 9681 in 2015. This category shows the most dramatic
increase. “Psychostimulants with abuse potential”, a category that includes
methamphetamine and prescription analogs to it, has been increasing steadily
over the past few years; it rose from 5114 deaths in 2014 to 6082 in 2015.
Here are the mortalities for each year for the most deadly substances, expressed as deaths per 100k population:
Here are the mortalities for each year for the most deadly substances, expressed as deaths per 100k population:
The chart above is from the CDC’s WONDER database, but it’s
a little misleading. Don’t think you can add together the deaths from each
substance to get a total, because there is significant overlap between categories.
Single-substance overdoses are actually pretty rare. A typical heroin overdose
actually involves two or three substances, so such a death might show up in,
say, the heroin, cocaine, and benzodiazepine line. Such a death would be
triple-counted if you made the mistake of summing the death totals for each
substance. Also, some of these deaths aren’t even marked as “drug overdoses.”
They are heart attacks or something else, but someone happened to write down
“heroin” or “other opioids” on the death certificate. This is somewhat rare;
usually if a drug is written down on the death certificate, the death is coded
as a drug overdose. But this explains the discrepancy between the numbers in
the above paragraph and the ones I will give below. Also, I’m excluding
suicides, murder, and “undetermined intent” in the charts and figures below.
The chart below is an update of a chart from an earlier post, illustrating the
rarity of single-substance overdoses. I found some of these surprising when I
first saw them (Click to enlarge, I realize the individual cells are small. Some rows are hidden, so the Total row might not match the sum of the column exactly in some instances):
To explore the details of what kinds of substances are found
in combination, you need to dig into the raw data files here. There is a record for each death that happened in the United States in 2015, which lists all the contributing causes of
that death. The CDC’s WONDER database is great, but it doesn’t allow you to
determine what drugs *in combination* are contributing to these poisoning
deaths. To see what kinds of substances are typically found in combination on a
death certificate, see here:
(To read the cross table, go across by row and say, “This
percent of [row label] poisonings also involves the substance [column label].”
Thus you get 100% across the diagonal.)
So, for example, benzodiazepines are extremely likely to be
found in conjunction with opioids. Alcohol is frequently found in conjunction
with other drugs. You get the sense from looking at the cross table that many
of these people would still be alive if they hadn’t been mixing drugs.
These drug interactions are a big deal, because a big
increase in mortality due to heroin can cause an increase in mortality due to
cocaine, even if the cocaine problem is declining. You can’t just look at the
graph above and say, “The prescription painkiller problem (mostly the ‘other
opioids’ curve) is getting worse, because it went up.” Looking at the cross
table, for those deaths with “heroin” stamped on the death certificate, about
20% involve cocaine, ~15% benzodiazepines, and ~11% “other opioids.” So a rise
of 3,000 heroin deaths per year (roughly what we saw from2014 to 2015) will result
in 600 additional “cocaine” deaths, 450 “benzodiazepines” deaths, and 330 “other
opioids” deaths. Likewise, the big spike in “Other synthetic narcotics” deaths
is going to drive up the deaths attributed to other substances. Roughly 20% of
these deaths involve other opioids, 18% involve benzodiazepines, and 17%
involve cocaine. So the roughly 4,000
additional “other synthetic narcotics” deaths will give us 800 additional “other
opioids” deaths and about 700 additional benzodiazepines and cocaine deaths. This
could be true even though there may be no additional users or perhaps even
fewer users of these other drugs. The problem is that a heroin habit is so
potentially deadly, and heroin users tend to use these other substances in
combination. Anyone looking at the raw totals by substance
will be misled if they aren’t thinking carefully about the poly-drug use
problem.
Be cautious interpreting the big jump in “other synthetic
narcotics.” I suspect that the year-to-year changes aren’t as big as the chart
above implies, but rather the reporting is getting more accurate. There have
been numerous media reports of multiple people overdosing at the same time in
the same city (even the same neighborhood) because of a bad batch of “heroin.”
Well, it’s not really heroin but actually something like fentanyl or something even stronger. The first responders don’t always know what drug is actually causing the drug
overdose. The lab testing required to figure out the exact substance sometimes takes weeks (citation needed, but I’m speaking from memory based on
an NPR story I heard months ago). I don’t expect that death certificates are
always updated after the test results come back. I think the big jump in this "other synthetic narcotics" category shows a growing awareness that this is what’s really happening in
these “heroin overdose” cases, most likely combined with a real increase in the
number of overdoses. So there's a real trend with a reporting trend on top of it.
Some will surely draw the wrong lesson from this most recent
year’s worth of CDC data. Some will say, ”The problem is bigger than ever, so
we need to hammer it even harder!” In reality, the rising heroin and fentanyl overdoses
are proving that drug prohibition isn’t working. Or in other words, prohibition is
having *exactly* the effect that its critics predict. Dealers are attracted to
drugs that are easiest to conceal, so they are opting for super-concentrated
opioids that are sometimes thousands of times stronger than heroin. You can
collapse a multi-ton shipment of heroin down to something the size of a
briefcase. But when it reaches the user, it may not have been diluted properly.
This problem is causing a lot of unnecessary overdoses. Ending prohibition would
pretty much fix the problem, because strict quality control on the drug supply would be possible under a legalization regime. Buyers could ensure that they are getting pharmaceutical grade heroin that hasn't been spiked with a lethal dose of fentanyl, and producers would subject themselves to outside audits, the results of which they could show to their customers. Producers would subject themselves to the threat of lawsuits if they mislabeled something. Such quality controls simply aren't possible under a prohibition regime.
One final note here. The CDC's method for counting "prescription opioid overdoses" used to be to count all deaths involving methadone, other opioids, and other synthetic narcotics, which up until 2013 might have been a reasonable methodology. No longer. Unless the spike in other synthetic narcotics deaths is driven entirely by a recent dramatic spike in fentanyl prescriptions, we should suspect that the heroin and other synthetic narcotics categories are bleeding into each other. Be very careful if you're reading anything that says that 2015 saw a "new maximum" in opioid deaths. They are either using an old and now dubious methodology for counting prescription opioids or they are surreptitiously adding prescription opioids to heroin without explaining that these are two different problems.
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