Synthetic Opioids Driving a Worsening Crisis of Overdose Deaths

Published on: April 14, 2021. Updated on: June 17, 2021.

Every 10.7 minutes

one person died of opioid overdose in 2019

These interactive graphics allow users to explore how the crisis of overdose deaths involving opioid use has not only grown in magnitude since 2000, but has also changed in character.

As the number of opioid overdose deaths grew more than eight-fold between 2000 and 2018 – reaching 49,047 deaths in 2019 – the minutes between deaths fell correspondingly. By 2019, one person was dying of an opioid overdose every 10.7 minutes.

Over this period, the crisis evolved in three well-documented waves. Initially, overdose deaths were predominantly linked to common prescription opioids, such as oxycodone and hydrocodone. By 2011, however, heroin was increasingly involved in overdose deaths, and beginning in 2014, there was an explosion in the number of deaths involving synthetic opioids such as fentanyl. Despite a decline in deaths involving prescription opioids and heroin in the since 2016, deaths involving synthetic opioids have continued to rise exponentially. Because a single death may involve multiple types of opioids, summing across the three categories in any year will overstate the total number of deaths in that year.

Although final death statistics are currently available from the CDC only through 2019, provisional data also compiled by the CDC show a sharp rise in opioid deaths just at the time when COVID-19 lockdowns began in March 2020. The rise is particularly notable for deaths involving synthetic opioids, but there were also upticks in deaths involving commonly prescribed opioids and heroin – both of which had been declining in recent years. Anxiety and despair over the pandemic situation may have contributed to greater drug use. Additionally, lockdowns made it challenging for people to receive in-person treatment for existing substance abuse problems, and social isolation made it more likely that people would be using these substances alone, with less chance of a rescue in case of an accidental overdose.

The three waves of the opioid crisis are also apparent when looking at temporal changes in the share of opioid deaths in a given year that involved each substance. At the beginning of the period, 65 percent of all opioid overdose deaths involved common prescription pain killers, but this figure had declined to 29 percent by 2019. Deaths involving heroin began playing a larger role in overdose deaths around 2011, before beginning to tail off after 2015, only to be supplanted by the very significant rise in the involvement of synthetic opioids. By 2019, 74 percent of all opioid deaths involved a synthetic product. Again, since multiple substances may be involved in a single death, the percentages reflecting the share of total deaths involving each substance will sum to more than 100 percent in a given year.

In the panel above, we present unduplicated counts of the number of deaths involving specific combinations of prescription opioids, heroin and synthetic opioids. It is apparent that a growing share of opioid deaths involve two or even all three of these substances, particularly in recent years.

For example, in the second tab, focusing on common prescription opioids, we see a leveling off and then a decline in the number of deaths attributable solely to this type of opioid (the dark blue segments), as well as the increasing involvement of heroin and/or synthetic opioids used in combination with prescription drugs. The majority of polysubstance deaths involve synthetic opioids.

In the third tab, we see deaths involving only heroin began to rise in 2011 and deaths involving both heroin and synthetic opioids increased rapidly from 2014 onward.

Finally, data presented in the fourth tab show not only the rising importance of synthetics as the sole cause of opioid overdoses, but also how common it has become for overdose deaths to involve synthetic products in combination with heroin and/or prescription opioids.

Coincident with the rise of heroin and synthetic opioids, both of which have much less predictable potency and purity than prescription pain killers, there has been a rapid increase in the number and share of opioid deaths ruled accidental. By 2019, 91 percent of all opioid overdose deaths were deemed to be accidental compared to 77 percent in 2000.

The burden of opioid deaths is spread unevenly across the U.S., particularly for deaths involving heroin and synthetic opioids. Synthetic opioid death rates are higher in the eastern portion of the U.S., as are deaths involving heroin. This phenomenon has been attributed to the fact that powdered heroin is typically used in this area of the country, and is more easily mixed with synthetic opioids, making for a potent and deadly combination. In contrast, the heroin used in the western portion of the country is a tar-like substance that does not mix easily with synthetic opioids, providing a small measure of protection against unintended heroin overdoses. For prescription opioids, while there are some state hot spots with elevated death rates, strong geographic patterns are harder to detect.

The opioid crisis has always touched all age groups, but in the early years when opioid abuse was primarily associated with prescription pain medications, the crisis was initially felt most acutely by adults in their 40s. Beginning around 2007 overdose deaths began to affect all age groups more equally. By the end of the period, when synthetic opioids had come to dominate the crisis, younger adults aged 25 to 40 were the hardest hit by overdose deaths.

Data and Methods
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Data on opioid overdose deaths were derived from the multiple cause of death files of the Wide-ranging Online Data for Epidemiologic Research (WONDER) data system maintained by the Centers for Disease Control and Prevention (CDC).

Deaths were identified as due to an opioid overdose if the ICD-10 code for the underlying cause of death was X40-X44 (accidental poisoning), X60-X64 (intentional self-poisoning) or Y10-14 (poisoning of undetermined intent) and if any of the multiple cause of death codes indicated that the type of substance involved in the poisoning was T40.1 (heroin), T40.2 (natural and semi-synthetic opioids), T40.3 (methadone) or T40.4 (synthetic opioids other than methadone). Because a single death may involve multiple substances, summing across the number of deaths involving each substance will overestimate the number of opioid-related overdoses. Following the classification scheme adopted by the CDC, methadone and natural and semi-synthetic opioids (e.g., oxycodone and hydrocodone) were grouped into a single category encompassing commonly prescribed opioids. Synthetic opioids other than methadone include substances such as tramadol and fentanyl (both pharmaceutically manufactured and illicitly manufactured). A small number of opioid deaths that were the result of homicide (underlying cause of death X85) were excluded from the analyses.

Provisional death data come from the CDC’s National Center for Health Statistics Provisional Drug Overdose Death Counts, and capture the same three substance categories used in other panels: heroin (T40.1); commonly prescribed opioids (T40.2 and T40.3); and synthetic opioids other than methadone (T40.4). Provisional death data are based on death records submitted by state vital registration offices and vary in their timeliness for both reporting and validation. The counts given for a specific month capture all death reports for the prior twelve-month period ending in that month, making the counts insensitive to variation in reporting across seasons. In addition to the raw provisional counts, the CDC also provides predicted provisional counts that have been adjusted to account for reporting and validation delays. The graphic we show is based on these predicted provisional counts. Provisional data are subject to change and are not strictly comparable with final annual death counts reported elsewhere.


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