Drug-Induced Deaths --- United States, 2003--2007

Leonard J. Paulozzi, MD

National Center for Injury Prevention and Control, CDC

Corresponding author: Leonard J. Paulozzi, MD, Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, 601 Sunland Park Drive, Suite 200, El Paso, TX 79912. Telephone: 770-365-7616; Fax: 915-834-5973; E-mail: lbp4@cdc.gov.

Drug-induced deaths include all deaths for which drugs are the underlying cause (1), including deaths attributable to acute poisoning by drugs (drug overdoses) and deaths from medical conditions resulting from chronic drug use. A drug includes illicit or street drugs (e.g., heroin or cocaine), as well as legal prescription drugs and over-the-counter drugs; alcohol is not included. The majority of deaths are unintentional drug poisoning deaths, with suicidal drug poisoning and drug poisoning of undetermined intent comprising the majority of the remainder (2). Adverse effects from drugs taken as directed and infections resulting from drug use are not included. In 2007, drug-induced deaths were more common than alcohol-induced or firearm-related deaths in the United States (1).

To examine trends and assess drug-induced deaths during 2003--2007 in the United States, CDC analyzed data from the mortality component of the National Vital Statistics System. Death certificates provide information on the sex, race, and ethnicity of the decedent; they do not provide information on decedent income. Deaths with underlying causes that are defined as drug induced by CDC are included in the category (1). Age-adjusted rates were calculated per 100,000 persons on the basis of U.S Census populations with bridged-race categories. Unadjusted rate ratios were calculated to compare 2007 to 2003 rates and to compare nonwhite with white rates. Rates were not compared by geographic region.

During 2007 (the year in which the latest national NVSS mortality data are available), a total of 38,371 drug-induced deaths occurred in the United States (Table). Drug-induced mortality rates increased during 2003--2006 and declined slightly in 2007. During all years, rates for males exceeded those for females. During 2007, rates for non-Hispanic white males (18.7 per 100,000 population) were 64.0% greater than those for non-Hispanic white females (11.4 per 100,000). Drug-induced mortality rate increases were greatest for non-Hispanic whites, whereas rates for Hispanics did not increase with time. The highest rates overall were among non-Hispanic whites for each year examined. Asians/Pacific Islanders had markedly lower rates than all other groups. For females, the highest rates were among American Indians/Alaskan Natives for every year except 2006. For males, the highest rates were among non-Hispanic blacks or non-Hispanic whites each year.

During the 1980s and 1990s, when the majority of drug-induced deaths were attributable to illicit drugs (e.g., heroin and cocaine), drug-induced mortality rates were higher among blacks than whites (2). However, in 2002, rates for whites surpassed those for blacks (2). This change occurred as prescription drugs, especially prescription opioid painkillers and psychotherapeutic drugs, were prescribed more widely by physicians. Prescribed drugs eventually supplanted illicit drugs as the leading cause of drug-related overdose deaths (3). Members of racial/ethnic minorities might have been less affected by this change because they are less likely to use prescription drugs and therefore might have been less likely to misuse such drugs (4). Studies of primarily white populations report that drug-related overdose death rates are highest among low-income persons; however, the reasons are unclear (5,6).

The findings in this report are subject to at least three limitations. First, because of the stigma associated with drug abuse, drug-induced death rates are likely to be underestimates. Whether the percentage of ascertainment varies by race/ethnicity is unknown. Second, because death certificate data are not timely, the differences noted in this report might have changed in subsequent years given the marked changes that occurred during 2003--2007. Finally, injury mortality data likely underestimate by 25%--35% the actual numbers of deaths for American Indian/Alaskan Natives and certain other racial/ethnic populations (e.g., Hispanics) because of the misclassification of race/ethnicity of decedents on death certificates (7).

Despite the lower income levels of most racial minorities, they are not more likely than whites to die from the effects of drugs. However, all racial/ethnic groups other than Hispanics have had increases in drug-induced death rates in recent years. Physicians should follow existing guidelines for cautious use of prescription drugs that tend to be misused by patients. Regulations designed to prevent illicit use of prescription drugs need to be strengthened and enforced. Persons who misuse prescription drugs should be identified and receive a referral for substance abuse treatment.

References

1. Xu JQ, Kochanek KD, Murphy SL, Tejada-Vera B. Deaths: final data for 2007. Hyattsville, MD: US Department of Health and Human Services, CDC, National Center for Health Statistics. National Vital Statistics Reports, Vol. 58, No. 19. Available at http://www.cdc.gov/nchs/data/nvsr/nvsr58/nvsr58_19.pdf.

2. Paulozzi LJ, Annest JL. US data show sharply rising drug-induced death rates. Inj Prev 2007;13:130--2.

3. Paulozzi LJ, Budnitz DS, Xi Y. Increasing deaths from opioid analgesics in the United States. Pharmacoepidemiol Drug Saf 2006;15:618--27.

4. CDC. QuickStats: Percentage of persons reporting use of at least one prescription drug during the preceding month, by sex and race/ethnicity---United States, 1999--2002. MMWR 2006;55:15.

5. CDC. Overdose deaths involving prescription opioids among Medicaid enrollees---Washington, 2004--2007. MMWR 2009;58:1171--5.

6. Hall AJ, Logan JE, Toblin RL, et al. Patterns of abuse among unintentional pharmaceutical overdose fatalities. JAMA 2008;300:2613--20.

7. Arias E, Schauman WS, Eschbach K, Sorlie PD, Backlund E. The validity of race and Hispanic origin reporting on death certificates in the United States. Vital Health Stat 2 2008;148:1--23.

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