The document outlines the public health crisis stemming from prescription opioid and heroin overdoses, highlighting a dramatic increase in mortality rates from 1999 to 2013. It emphasizes the role of high prescribing rates and multiple prescribers in overdose risks, particularly among middle-aged white Americans. Conclusively, it calls for a multifaceted approach to address the epidemic, focusing on effective interventions and evaluation of state-specific solutions.

1. Overview of the Public Health
Burden of Prescription Drug
and Heroin Overdoses
Grant Baldwin, PhD, MPH
December 1, 2015

2. How We Got to Now?

3. 145,000
Rx opioid deaths in 10 years.
4x as many deaths
In 2013 as 1999.

5. Rise in Rx overdose deaths since 1999 and
recent increase in heroin deaths
CDC, National Center for Health Statistics, National Vital Statistics System
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Prescription
Opioids
Heroin

6. Mortality is
rising among
Middle-Aged
White Americans
Rx Drugs & Heroin
Suicide
Alcohol Poisoning
Driving Increase
Case & Deaton. Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century, 2015.
USW – US Whites
FRA – France
GER – Germany
USH – US Hispanics
UK – United Kingdom
CAN – Canada
AUS – Australia
SWE - Sweden

7. For every Rx opioid overdose death in 2011,
there were...
SAMHSA NSDUH, DAWN, TEDS data sets.
0 100 200 300 400 500 600 700
12treatment admissions for opioids
25 emergency department visits for opioids
105 people who abused or were dependent on opioids
659nonmedical opioid users

8. Quarter billion
opioid prescriptions in 2012

9. Number of painkiller
prescriptions per
100 people
52–71
72–82.1
82.2–95
96–143
HI
Opioid prescribing can vary
3-fold between states
Paulozzi et al. (2014) MMWR 63(26), 563-8.

10. Sharp increases in opioid prescribing coincides with
sharp increases in Rx opioid deaths
0
1
2
3
4
5
6
7
8
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
National Vital Statistics System, DEA’s Automation of Reports and Consolidated Orders System.
Opioid Sales (kg per 10k)
Rx Opioid Deaths (per 100k)

11. States with more opioid pain reliever sales tend to
have more drug overdose deaths
Death rate, 2013, National Vital Statistics System. Opioid pain reliever sales rate, 2013, DEA’s Automation of Reports and
Consolidated Orders System

12. The Role of Opioid Prescribing
Upper Midwest Appalachia
Death rate, 2013, National Vital Statistics System. Opioid pain reliever sales rate, 2013, DEA’s Automation of Reports and Consolidated Orders System

13. 0
200
400
600
800
1000
1200
California Delaware Florida Idaho Louisiana Maine Ohio
PrescribingRateper1,000Population
Opioids Stimulants Benzodiazepines
Wide variation in prescribing by state and class of drug
Source: Paulozzi et al. (2015). Controlled substance prescribing patterns in eight states. MMWR 64(SS-9), 1-14.
Opioid Prescribing Approaching
1 Prescription Per Resident

14. 0 2,000 4,000 6,000 8,000 10,000 12,000
≥65
55–64
45–54
35–44
25–34
18–24
<18
Prescribing Rate per 1,000 Population
AgeGroup
California Delaware Florida Idaho Louisiana Maine Ohio West Virginia
Opioid prescribing greatest between ages 45 and 64
Source: Paulozzi et al. (2015). Controlled substance prescribing patterns in eight states. MMWR 64(SS-9), 1-14.
}
Peak
Prescribing
Ages

15. A small fraction of
prescribers fueling the problem
Swedlow et al. Prescribing patterns of schedule II opioids in California Workers’ Compensation, CWCI Institute, 2011
CA Workers
Compensation
Program

16. Swedlow et al. Prescribing patterns of schedule II opioids in California Workers’ Compensation, CWCI Institute, 2011
55% of CSII opioid Rx
62% of morphine equivalents
65% of associated payments
3 Percent Prescribe. . .

17. Primary care providers prescribe the most opioids
IMS Health, National Prescription Audit, United States, 2012
Pain specialists prescribe opioids most frequently

18. Half of US Opioids Market is Treatment for
Chronic, Non-Cancer Pain
Cancer
Post Operative Care
Fibromyalgia
Neuropathic Pain
Osteoarthritis
Rheumatoid Arthritis
Low Back Pain
{50%
U.S. opioids market revenues
7 leading indications - 2010
Source: GBI Research. Opioids Market to 2017. June 2011

19. Who is at risk for an overdose?
Risk Factors
 Patients receiving opioids
from multiple prescribers
and/or pharmacies
 Patients taking high daily
doses of opioids
Demographics
 Men
 35-54 year olds
 Whites
 American Indians/Alaska
Natives
Socioeconomics & geography
 Medicaid
 Rural

20. JAMA 2011;305:1315-1321

21. Kaplovitch et al, 2015
1 in 55
Patients escalating to high dose
opioid therapy
1 in 550
Patients dying from opioid-related cause
Chronic Opioid Therapy
Ontario, Canada – Cohort Study – 1997-2010

22. Majority of opioid overdose deaths associated
with multiple sources and/or high dosages
94%
45%
6%
55%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Control Patients Patients w/ Fatal Overdose
Multiple sources (> 3
prescribers or pharmacies)
and/or high dosages (>100
MME) of opioids
Fewer sources and
dosages of opioids
Baumblatt JAG et al. High Risk Use by Patients Prescribed Opioids for Pain and its Role in Overdose Deaths. JAMA Intern Med 2014; 174: 796-801.

23. Methadone contributes to largest
fraction of opioid-related deaths
Death rate from overdoses when
single prescription painkiller involved

24. 3 3 3
15
29
122
0
20
40
60
80
100
120
140
Low (36 mg or less) Medium (36 to 120 MME) High (120 MME or more)
adustedOR
adjusted OR for opioid use disorder (abuse or dependence) compared with no opioid use
90 or fewer days more than 90 days
Longer durations and higher doses of opioid treatment
are associated with opioid use disorder
Edlund, MJ et al.The role of opioid prescription in incident opioid abuse & dependence among individuals with chronic noncancer pain. Clin J Pain 2014; 30: 557-564.
opioid dose

25. HIV and HEP C Outbreak
2015
 135 new HIV infections diagnosed in town of
4,200 people – Austin, Indiana.
 Co-infection with hepatitis C virus in 84% of
patients
 Spread by Injection Drug Users using
OPANA. Daily injections ranged from 4 to 15.
 Average of nine syringe-sharing partners,
sex partners, or other social contacts
 Reported number of injection partners
ranged from 1 to 6 per injection event
SOURCE: Conrad, C. et al. (2015). Community outbreak of HIV infection linked to injection drug use of oxymorphone—Indiana,
2015. MMWR Morb Mortal Wkly Rep, 64(16), 443-444..

26. Schumacher and Benneyworth, 2012
225% Percent
Increase in Neonatal Abstinence Syndrome
live births from 2000 to 2009

27. Trends in Heroin Use
& Health Outcomes

28. Prescription opioid misuse is a major risk
factor for heroin use
Jones, C.M., Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers – United States, 2002–
2004 and 2008–2010. Drug Alcohol Depend. (2013).
3 out of 4 people
who used heroin in the
past year misused
opioids first
7 out of 10 people
who used heroin in the
past year also misused
opioids in the past year

29. Heroin overdose deaths nearly four times
higher for men than women
CDC/NCHS, National Vital Statistics System, Mortality.

30. Adults age 25-44 have the highest rate of
heroin overdose
CDC/NCHS, National Vital Statistics System, Mortality.

31. Recent increase in heroin overdose deaths are not
associated with decreases in Rx opioid deaths
18 States - 2010-2012
Rudd RA et al. Increases in heroin overdose deaths – 28 states, 2010 to 2012. MMWR Weekly 2014; 63: 849-854.
-2.0
-1.0
0.0
1.0
2.0
3.0
4.0
-4.0 -3.0 -2.0 -1.0 0.0 1.0 2.0 3.0 4.0
AbsoluteRateChange-Heroin
Absolute Rate Change - Prescription Opioid Pain Relievers

33. 500% Increase in 2014
Fentanyl-Related Deaths in Ohio

34. Two groups of people with two different
sets of needs
Addicted/Dependent
Need access
to services
At risk for addiction/dependence
Protect from
dangerous drugs

35. Conclusions
 BURDEN: Overdose deaths from
prescription drugs & heroin are at epidemic
levels in the U.S.
 KEY DRIVERS: Understanding the epidemic
drivers is critical for effective action. Address
prescribing.
 SCOPE OF SOLUTION: Multifaceted and
multi-sector approach is needed.
 KNOWN EFFECTIVENSS: Interventions
must be evaluated to determine effectiveness
and need for state-specific adaptation.

36. For more information please contact Centers for
Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA 30333
Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-
6348
E-mail: cdcinfo@cdc.gov Web: www.cdc.gov
The findings and conclusions in this report are those of the authors and do not
necessarily represent the official position of the Centers for Disease Control
and Prevention.