Drug Poisoning Data from 2016

I have the aggregated data from the CDC's Wonder database, not the individual death record level data. So we'll at least see what that shows. (I just checked just now. The individual death record data isn't out yet. Not sure why it takes over a year to publish this stuff.)

Below are the raw death totals for the most lethal substances (excluding alcohol; tobacco is also lethal but from cumulative harm, not from acute poisoning). Careful interpreting this. Most drug poisoning deaths are multi-drug interactions, not single drug poisonings. So if you try to add these together you will vastly overstate the number of total deaths. I have seen articles that make this embarrassing mistake. (Click directly on the graph for a cleaner display.)

Here are the death rates per 100k population.

Here's what I see.

Heroin (thick yellow line) is continuing a trend started in ~2011.

"Other Synthetic Narcotics" (dark blue) includes fentanyl and other substances that are many times stronger than heroin. It is continuing a dramatic increase that began in 2014, following a steady increase from 1999 to 2005 and a roughly flat trend from 2006 to 2013. Like I've said, this is a product of prohibition. There would basically be no demand for recreational fentanyl if there were a legal market for recreational opioids. This very high death toll is totally unnecessary.

Cocaine (orange) deaths are up above their 2006 peak. For a long time, cocaine was the most lethal drug, but use rates and death rates both started declining after 2006. Cocaine use is flat; it didn't spike up in recent years and is basically unchanged in 2016. (See page 17 here.) So cocaine use is getting deadlier. Mike Riggs at Reason Magazine has written about reports of cocaine laced with fentanyl. This spike in cocaine deaths, along with the continuing rise of synthetic narcotics deaths, seems to corroborate those reports. When the CDC finally publishes the individual death records data, I can look at those and see if the co-incidence of cocaine and "other synthetic narcotics" to see if it rose in 2016. I'll just go on record here predicting that is has.

"Psychostimulants with abuse potential" (pink) includes things like methamphetamine and prescription drugs like Adderall. Meth is chemically almost identical to ADHD drugs, and in fact the government tracks both deaths and use rates for these substances in the same category. (So if you hear someone comparing meth and Adderall, don't assume it's a hyperbolic libertarian drug legalizer shooting from the hip. They're basically in line with official government statistics on drug abuse and the ICD-10 coding system.) People don't usually overdose from these drugs. The same is true of cocaine. I believe there is the occasional fatal arrhythmia from using too much of a stimulant; the same is possible with caffeine. I suspect this is another "tainted with fentanyl" story. Again, I'll report back when I look at the individual death records. I predict I'll see a large uptick in this category overlapping with the "other synthetic narcotics" category, meaning a lot of drug poisonings involved both classes of substances. Use rates of stimulants have basically been flat for a decade and a half.
See page 9 of the 2014 SAMHSA report here; in the 2016 version linked to above, use rates are still at the 0.6 percent of the population, right were it left off in 2014.

(Incidentally I don't know why the people at SAMHSA decline to give time series when they are 1) readily available and 2) relevant to policy discussions. Methodology change? Fine, so show all the data and disclose the methodology change. For example: "The spike/decrease in 2015 is most likely due to a change in the survey question." It's not that hard. I'm thinking someone who is trying to interpret trends in drug poisonings would want to know something about trends in use rates. In my experience, the only people who give this much careful attention to detail are the skeptics of the official standard opioid epidemic narrative.)

Benzodiazepines (purple) and "other opioids" (light blue) are both up, after flattening in 2010. Once again, there is a lot of overlap. Again, I suspect the rising heroin/fentanyl overdoses are driving up the numbers for these drugs. I'll know for sure when I see the detailed 2016 data. Notice how closely these lines follow each other. I've written about this before. Something like 1/3 of prescription opioid poisonings involve benzodiazepines, and something like 85% of benzodiazepine-related deaths involve some kind of opioid (based on the 2015 data I have at my fingertips). The "benzodiazepines" story is really an "opioid interaction" story, and I wish people writing about this emphasized the multi-drug nature of these poisonings. We'd save a lot of lives if we just adopted harm reduction. It's pointless to try to get people to stop indulging entirely, but we can at least educate them on the safest ways to imbibe.

Methadone (green) is continuing its downward trend. I'm not really sure what's going on. In about 2006 people realized that methadone was kind of dangerous for pain management because it has such a long half-life and low cross-tolerance with other opioids. Doctors stopped prescribing it for pain and instead prescribed other opioids like vicodin and oxycontin.

I wish people who wrote about the "opioid epidemic" would be clearer about their timelines. I'm reading a book called Dreamland by Sam Quinones. He lays out the basic standard narrative of the current epidemic:

Doctors became loose with the prescription pad because of a new philosophy of treating chronic pain. Abuse of prescription opioids exploded. Heroin got cheaper, so people with a medically-acquired taste for opioids switched to heroin. 

It all sounds very neat and tidy, but the timeline is all wrong. The revolution in doctors' attitudes about pain started in the 80s. The spike in heroin deaths didn't happen until 2010. Dreamland follows the story of a cartel that sold Mexican black tar heroin in the 1990s and 2000s, but that can't possibly explain the sudden recent increase. The steady rise in prescription opioid deaths from 1999 to 2010 follows a tripling of legal prescriptions over that same time period, but as I've said before illicit use of prescription narcotics was flat, possibly even declining, over that time period. Did prescription narcotics abuse skyrocket up until 2002 (when the SAMHSA use data starts), then level off? Why is this out of sync with the overdose data? Where is the drug use survey data prior to this period, and what does it say? What do drug overdose trends look like in the 1980-1999 era? These were under a different coding system (ICD-9 as opposed to ICD-10), but if the data exist let's at least take a look. It's much more plausible that the very recent spike in heroin and fentanyl overdoses is a product of prohibition. If this very successful Mexican cartel was disrupted by law enforcement, that would bring new players into the market. Maybe that's where all this fentanyl is coming from. It could very well be that the successful Mexican cartel, by maintaining a consistent quality, decreased heroin overdose deaths. Anyway, it's hard to blame what you see in the figures above on a revolution in doctors' attitudes toward pain management that happened two or three decades ago.