John F Peppin 1 2 3, John J Coleman 4
In a 2018 report titled, Quantifying the Epidemic of Prescription Opioid Overdose Deaths, four senior analysts of the Centers for Disease Control and Prevention (CDC), including the head of the Epidemiology and Surveillance Branch, acknowledged for the first time that the number of prescription opioid overdose deaths reported by the CDC in 2016 was erroneous. The error, they said, was caused by miscoding deaths involving illicitly manufactured fentanyl (IMF) as deaths involving prescribed fentanyl. To understand what caused this error, the authors examined the CDC's methodology for compiling drug-related mortality data, beginning with the source data obtained from approximately 2.8 million death certificates received each year from state vital statistics registrars. Systemic problems often begin outside the CDC, with a surprisingly high rate of errors and omissions in the source data. Using the CDC's explanation for what caused the error, the authors show why an international program used by the CDC for reporting mortality is ill-suited for compiling and reporting drug overdose deaths. Except for heroin, methadone, and opium, each of which has an individual program code, all other opioids are separated in just two program codes according to whether they are synthetic or semisynthetic/opiates. Methadone-involved deaths pose a special problem for the CDC because methadone has dual indications for treating pain and for treating opioid use disorder (OUD). In 2019, more than seven times more methadone was administered or dispensed for OUD treatment than was prescribed for pain, yet all methadone-involved deaths are coded by the CDC as involving the prescribed form of the drug. The authors conclude that the CDC was at fault for failing to recognize and correct this problem before 2016. Public policy consequences of this failure are briefly mentioned.
Keywords: Centers for Disease Control and Prevention (CDC); Death certificates; Illicitly manufactured fentanyl (IMF); International Classification of Diseases (ICD); Methadone; Prescription opioid overdose deaths.
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Fig. 1 How mortality source data are collected in the U.S. and converted into vital statistics. (source: Robert N. Anderson, Ph.D., Chief, Mortality Statistics Branch, Centers for Disease Control and Prevention; permission granted 02/25/2021)
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Fig. 2 A chart showing the T-codes for opioids as categorized by the International Classification of Diseases, Tenth Edition, 1999–2022 (ICD-10) (Chart source: )
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Fig. 3 National drug-involved overdose deaths (including unintentional drug poisoning, suicide drug poisoning, homicide drug poisoning, or drug poisoning of undetermined intent as coded according to the International Classification of Diseases, 10th edition (ICD-10). Data are from Centers for Disease Control and Prevention (CDC, National Center for Health Statistics; Multiple Cause of Death 1999–2019 on CDC WONDER Online Database, released 12/2020; available at: https://wonder.cdc.gov/. (Permission to use graph granted by Josie Anderson, MA, Digital Media Manager, National Institute on Drug Abuse, National Institutes of Health to author John J. Coleman, Ph.D., on 02.25.2021). Original NIDA graphic adapted for use in Fig. 3 is available at: https://www.drugabuse.gov/drug-topics/trends-statistics/overdose-death-rates
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Fig. 5 Prescribing volumes in grams of four popular T-40.4 “synthetic opioids other than methadone” for years 2013, 2014, 2015, and 2016. Data are from Retail Drug Summary Reports of the Automated Reports and Consolidated Orders System (ARCOS) that is managed by the Drug Enforcement Administration (DEA). They reflect distributions to U.S. retail pharmacies for use in filling prescriptions. These reports are available online at: https://www.deadiversion.usdoj.gov/arcos/retail_drug_summary/index.html
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