Urban-Rural Differences in Drug Overdose Death Rates, 1999-2019

March 17, 2021

Questions for Holly Hedegaard, Health Statistician and Lead Author of “Urban-Rural Differences in Drug Overdose Death Rates, 1999-2019.”

Q: How do drug overdose death rates in urban and rural areas compare?

HH: Over the past 20 years, rates of drug overdose deaths have increased in both urban and rural areas. Rates in rural areas were higher than in urban areas from 2007 through 2015, but in 2016 that pattern changed. From 2016 through 2019, rates have been higher in urban areas than in rural areas.

Although urban rates are higher than rural rates nationally, for 5 states (California, Connecticut, North Carolina, Vermont, and Virginia), rates are higher in rural areas than in urban areas.


Q: Is this the most recent data you have on this topic?  When do you plan on releasing 2020 data?

HH: Final 2020 data won’t be released until the end of 2021. In the interim, monthly provisional estimates of drug overdose death rates are available at https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm


Q: Was there a specific finding in the data that surprised you from this report?

HH: In this report, we looked at trends in rates for drug overdose deaths involving certain types of opioids, including natural and semisynthetic opioids. This group includes such drugs as hydrocodone, oxycodone, and codeine – drugs that are often thought of as prescription opioids. In looking at the trends from 1999 through 2019, the rates of drug overdose deaths involving natural and semisynthetic opioids were higher in rural than in urban areas from 2004 through 2017, but in 2018 and 2019, the urban and rural rates were similar, because of a decline in the rates in rural areas. We will continue to monitor whether this decline in the rate continues.


Q: What is the take home message for this report?

HH: The key messages from this report are: 1) for the past 20 years, drug overdose death rates have increased in both urban and rural areas, and 2) there are urban-rural differences in the rates of drug overdose deaths involving specific types of drugs. For example, for the past 20 years, rates of drug overdose deaths involving cocaine or heroin have been consistently higher in urban areas than in rural areas. In contrast, in recent years, rates of drug overdose deaths involving psychostimulants (such as methamphetamine) have been higher in rural areas than in urban areas.


Q: Do you think rural counties will go back to having higher drug overdose death rates in the future?

HH: It’s impossible to predict what will happen in the future. While a lot of resources have been devoted to prevention and treatment of drug overdose in recent years, new drugs are becoming available all the time. NCHS will continue to monitor drug overdose deaths to identify patterns to help inform public health efforts.


Opioid-involved Emergency Department Visits in the National Hospital Care Survey and the National Hospital Ambulatory Medical Care Survey

December 15, 2020

Questions for Geoffrey Jackson, Health Statistician and Lead Author of “Opioid-involved Emergency Department Visits in the National Hospital Care Survey and the National Hospital Ambulatory Medical Care Survey.”

Q: Why did you decide to research opioid-involved emergency department (ED) visits?

GJ: From 2005 through 2014, it is estimated that the rate of ED visits due to opioid use increased 99.4%, from 89.1 per 100,000 population in 2005 to 177.7 per 100,000 population in 2014. We were struck by the large increase and know that ED data can provide critical information on opioid use-related treatments, such as opioid use disorder treatment, detoxification for safe opioid withdrawal, and management of adverse effects. NCHS hospital surveys can be used to monitor trends in opioid overdoses, as well as other opioid-related morbidity and mortality measures.


Q: Can describe the difference between the difference between the National Hospital Care Survey and the National Hospital Ambulatory Medical Care Survey?

GJ: Even though both surveys collect data from hospital emergency departments, the mode of data collection differs between the two surveys. The National Hospital Care Survey (NHCS) is an all-electronic data collection of administrative claims or billing data. NCHS receives all inpatient, ED, and outpatient hospitals for a calendar year.  In addition, to patient demographics, diagnoses, procedures, laboratory tests, and medications, NHCS collects patient name, address, and Social Security number, which allows patients to be followed over time and linkage to external data sources, such as the National Death Index, providing a more complete picture of patient care and post-acute mortality.

In contrast, the National Hospital Ambulatory Medical Care Survey (NHAMCS) data collection relies on medical record abstraction by U.S. Census Bureau field representatives during a 4-week period. A random sample of about 100 ED visits are selected from all visits during the reporting period, and data are manually abstracted directly from medical records by Census staff. NHAMCS collects similar information as NHCS, but NHAMCS does not collect patient identifiers.  As a consequence, NHAMCS data cannot be linked to other sources nor can patients be collected over time.


Q: Was there a specific finding in the data that surprised you from this report?

GJ: One finding that surprised me was the increase in percentage the patients that died of an opioid overdose 90 days after their hospital visits. Specifically, of the patients with an opioid-involved ED visit that died with 91 and 365 days after their ED visit, 20.6% died with an opioid overdose, compared to approximately 15% that died within 90 days post-ED visit died of an opioid overdose.


Q: Is this the most recent data you have on this topic?

GJ: The most recent NHCS data available in the NCHS Research Data Center (RDC) are from 2016. The 2016 NHCS data are linked to the 2016 and 2017 National Death Index and include information on specific drugs mentioned on the death certificate from the Drug-Involved Mortality file. Additionally, the 2016 NHCS RDC data include identification of opioids using an enhanced methodology that uses natural language processing and machine learning techniques. The most recent NHAMCS public use data file available are from 2018.


Q: What is the take home message for this report?

GJ: NHCS is an important data source for studying opioid-involved ED visits. Through the collection of patient identifiers, the data can be linked to the National Death Index to provide information on post-acute mortality. The information on post-acute mortality is not available in other hospital data sources. Even though the NHCS data are not nationally representative, the NHCS data have similar distributions to NHAMCS data for national estimates of ED visits of male and female opioid-involved ED visits and for persons aged 35 and over.


Prevalence of Prescription Pain Medication Use Among Adults: United States, 2015–2018

June 24, 2020

FROM THE AUTHOR

In 2015–2018, 10.7% of U.S. adults used one or more prescription pain medications in the past 30 days.  Prescription pain medication use was higher among women than men overall and within each age category. Use increased with age overall and among men and women. Prescription pain medication use was lowest among non-Hispanic Asian adults, and use among Hispanic adults was lower than among non-Hispanic white adults. This same pattern of prescription pain medication use was observed among both men and women.

Additionally, this report estimated the percentage of adults who used one or more opioid prescription pain medications (with or without use of non-opioid prescription pain medications) and the percentage who used one ore more non-opioid prescription pain medication (without use of prescription opioids).  In 2015–2018, 5.7% of U.S. adults used prescription opioids and 5.0% used non-opioid prescription pain medications (without prescription opioids) in the past 30 days. Use of one or more prescription opioids and use of non-opioid prescription pain medications (without prescription opioids) were higher among women than men, and increased with age, and were lowest among non-Hispanic Asian adults.  Use of one or more prescription opioids among Hispanic adults was lower than among non-Hispanic white adults.

From 2009–2010 to 2017–2018, there was no significant increase in use of prescription opioids, but use of non-opioid prescription pain medications (without prescription opioids) increased.

Source: National Health and Nutrition Examination Survey, 2015–2018.


Provisional Drug Overdose Death Counts (thru November 2019)

June 17, 2020

Source: https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm


Provisional Drug Overdose Death Counts (thru September 2019)

April 16, 2020

Provisional data in the United States shows that the reported number of drug overdose deaths occurring in the United States decreased by 0.9% from the 12 months ending in September 2018 to the 12 months ending in September 2019, from 68,421 to 67,839.

Link: https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm


QuickStats: Percentage of Emergency Department Visits for Pain at Which Opioids Were Given or Prescribed, by Geographic Region of the Hospital — United States, 2005–2017

January 17, 2020

The percentage of emergency department visits for pain at which an opioid was given or prescribed increased from 37.4% in 2005 to 43.1% in 2010 and then decreased to 30.9% in 2017.

A similar pattern was observed in all four regions. Percentages for the Northeast were lower than for the nation as a whole for all years analyzed.

In 2017, the percentage was 21.1% in the Northeast, compared with 32.0% in the Midwest, 32.0% in the South, and 34.7% in the West.

Source: National Center for Health Statistics. National Hospital Ambulatory Medical Care Survey, 2005–2017. https://www.cdc.gov/nchs/ahcd/ahcd_questionnaires.htm.


Trends in Opioids Prescribed at Discharge From Emergency Departments Among Adults: United States, 2006–2017

January 8, 2020

Questions for Lead Author Anna Rui, Health Statistician, of “Trends in Opioids Prescribed at Discharge From Emergency Departments Among Adults: United States, 2006–2017.”

Q: Why did you decide to look at opioid prescribing at emergency department discharges?

AR: There is a large body of research reporting increases in opioid prescription rates from 1999 to 2010 but less is known about how rates have changed from 2010 on, particularly in the emergency department setting, where many patients present with pain symptoms and are likely to receive opioids for treatment. In response to the opioid epidemic, hundreds of local, state, and federal programs were implemented in recent years with the goal of changing prescribing practices. A goal of this report was to evaluate recent trends in opioid prescribing, in order to monitor the effects of public health policy.


Q: How did the data vary by patient/hospital characteristics and in the type of opioids prescribed at discharge?

AR: Variation in the rate of change was found for age, patient residence, and primary expected source of payment. The rate of decrease in the percentage of visits with an opioid prescribed at discharge by younger patients aged 18-44 from both the beginning of the study period (2006-2007) and from the inflection point (2010-2011) to the end of the study period (2016-2017) was the highest across all age groups. Similarly, the percentage of visits by patients living in medium or small metropolitan counties decreased by the highest percentage across the study period among all urban and rural categories. Both Medicaid and self-pay/no charge/charity experienced the highest rate of decrease from 2010-2011 through 2016-2017 whereas the percentage of visits by patients with Medicare that included an opioid prescribed at discharge remained stable across the study period.

In terms of hospital characteristics, among the four regions, the largest decrease in opioids prescribed at discharge from 2006-2007 to 2016-2017 was observed in the Northeast region. Generally, a higher percentage of visits at proprietary (or for-profit) hospital EDs, compared with nonprofit and government hospital EDs, included an opioid prescribed at discharge. Despite the high percentage, the rate of decrease among visits made to proprietary hospital EDs from 2006-2007 through 2016-2017 was modest.

In terms of the type of opioids prescribed, the percentage of opioid mentions with acetaminophen-hydrocodone (e.g., Vicodin) prescribed remained stable through 2012-2013 and decreased starting from 2014-2015. Corresponding to this decrease, the percentage of opioid mentions with tramadol and acetaminophen-codeine, which are known as having a lesser risk of dependence, increased starting in 2014-2015 and continued through 2016-2017.


Q: Was there a specific finding in the data that surprised you?

AR: One finding that surprised me was the magnitude of decrease in the percentage of opioids prescribed from 2010-2011 through 2016-2017 for most of the pain-related diagnoses. For example, the percentage of visits for extremity and back pain decreased by 68.8% and 49.1%, respectively, between 2010-2011 and 2016-2017.


Q: How did you obtain this data for this report?

AR: Restricted data (available from the Research Data Center) collected from the National Hospital Ambulatory Medical Care Survey were used for this report. Masked public use data are available for download from the Ambulatory Health Care Data website (https://www.cdc.gov/nchs/ahcd/datasets_documentation_related.htm)


Q: What is the take home message for this report?

AR: I think the take home message of the report is recent trends show a decrease in the percentage of visits with opioids prescribed at discharge from 2010-2011 through 2016-2017, and this trend was observed for most of the patient and hospital characteristics examined, as well as for most of the pain-related diagnoses prompting the ED visit.


Regional Differences in the Drugs Most Frequently Involved in Drug Overdose Deaths: United States, 2017

October 25, 2019

NCHS report describes regional differences in the specific drugs most frequently involved in drug overdose deaths in the United States in 2017.  Data from the 2017 National Vital Statistics System–Mortality files were linked to electronic files containing literal text information from death certificates.

Key Findings: 

  • Among drug overdose deaths in 2017 that mentioned at least 1 specific drug on the death certificate, the 10 drugs most frequently involved included fentanyl, heroin, cocaine, methamphetamine, alprazolam, oxycodone, morphine, methadone, hydrocodone, and diphenhydramine.
  • Regionally, 6 drugs (alprazolam, cocaine, fentanyl, heroin, methadone, and oxycodone) were found among the 10 most frequently involved drugs in all 10 HHS regions, although the relative ranking varied by region.
  • Age-adjusted rates of drug overdose deaths involving fentanyl or deaths involving cocaine were higher in the regions east of the Mississippi River, while age-adjusted rates for drug overdose deaths involving methamphetamine were higher in the West.
  • The regional patterns observed did not change after adjustment for differences in the specificity of drug reporting.

Opioids Prescribed at Discharge or Given During Emergency Department Visits Among Adults in the United States, 2016

May 31, 2019

Questions for Lead Author Anna Rui, Health Statistician, of “Opioids Prescribed at Discharge or Given During Emergency Department Visits Among Adults in the United States, 2016.”

Q: Why did you decide to focus on opioids prescribed at discharge or given during emergency department visits in the United States for this report?

AR:

Prescription opioid abuse and overdose continue to be critical public health issues. Opioid misuse, abuse, and overdose are affected by multiple factors including the number of people exposed. The Emergency Department (ED) is one setting where people could become exposed to opioids. In 2016, 27.5% of adult ED visits included opioids given in the ED, prescribed at ED discharge, or both (data not shown in report). The ED setting is where people frequently receive their first opioid treatment, after which patients with moderate to severe pain are often sent home with a prescription for an opioid, leaving them with the option of filling/not filling the prescription, or diverting filled prescriptions.

In the National Hospital Ambulatory Medical Care Survey (NHAMCS), information is collected on whether drugs are given during the ED visit, prescribed at discharge, or both.  However, in our published reports, the focus is on estimates of drugs and visits with drugs rather than how they are administered.  I wanted to assess visits with opioids prescribed at discharge separately to see how they compared with those given in the ED, in order to glean new information that has not previously been reported.  This could hopefully provide additional insight into patient populations visiting the ED who are exposed to opioids.


Q: How do rates of visits with opioids only given in the ED compare with opioids only prescribed at discharge and visits with both given and prescribed opioids?

AR: Generally, the rate of ED visits with opioids given during the visit was higher than the rate of ED visits with opioids prescribed at discharge.  Compared with the rate of ED visits with opioids prescribed at discharge, the rate where opioids were only given in the ED was higher among patients aged 45 and over and for both women and men.  Adults aged 18-44 were more likely to receive a prescription for an opioid at discharge compared with adults 45 and over.


Q: How did the data vary by emergency department visits where opioids were given, prescribed or both by primary diagnosis?

AR: The type of opioid administration among ED visits where opioids were given, prescribed, or both varied for certain selected diagnoses. For visits with a primary diagnosis of injury or trauma with opioids given or prescribed, the percentage with opioids only prescribed at discharge (40.7%) was higher than both the percentage of visits with opioids only given at the ED visit (26.3%) and visits with opioids both given and prescribed at discharge (32.7). Conversely, at visits for chest pain and abdominal pain with opioids given and/or prescribed, a higher percentage of opioids were only given at the ED visit. There was no variation across the types of opioid administration for back pain and extremity pain.


Q: Was there a specific finding in your report that surprised you?

AR:I was surprised at the high percentages of visits with opioids prescribed at discharge compared with those only given in the ED for certain diagnoses.  For example, among visits with a primary diagnosis of injury or trauma and where opioids were given or prescribed, a total of 73.4% included an opioid prescription at discharge.  Among visits primarily for extremity pain and where opioids were given or prescribed, 67.9% included an opioid prescription at discharge. Finally, among visits primarily for back pain in which opioids were given or prescribed, 64.5% included an opioid prescription at discharge. However I should also note that these estimates are based only on visits where the patient got opioids during the visit or at discharge.  For example, there are other ED visits made for injury where the patient did not get opioids at all, but we did not assess this in the report.


Q: Do you foresee the number of prescription opioids at emergency department visits increasing in the future?

AR: We do not make predictions about future data trends, but other research published by CDC for recent years showed stable or declining trends in the percentage of visits with opioids given in the ED, prescribed at discharge, or both.


Prescription Opioid Analgesic Use Among Adults: United States, 1999–2012

February 25, 2015

Prescription opioid analgesics are used to treat pain from surgery, injury, and health conditions such as cancer. Opioid dependence and opioid-related deaths are growing public health problems. Opioid analgesic sales (in kilograms per 10,000) quadrupled from 1999 to 2010, and from 1999 to 2012, opioid-related deaths (per 100,000) more than tripled. During 1999–2002, 4.2% of persons aged 18 and over used a prescription opioid analgesic in the past 30 days.

A new NCHS report provides updated estimates and trends in prescription opioid analgesic use among adults aged 20 and over, overall and by selected subgroups.

Key Findings from the Report:

  • From 1999–2002 to 2003–2006, the percentage of adults aged 20 and over who used a prescription opioid analgesic in the past 30 days increased from 5.0% to 6.9%. From 2003–2006 to 2011–2012, the percentage who used an opioid analgesic remained stable at 6.9%.
  • From 1999–2002 to 2011–2012, the percentage of opioid analgesic users who used an opioid analgesic stronger than morphine increased from 17.0% to 37.0%.
  • During 2007–2012, the use of opioid analgesics was higher among women (7.2%) than men (6.3%).
  • During 2007–2012, the use of opioid analgesics was higher among non-Hispanic white adults (7.5%) compared with Hispanic adults (4.9%). There was no significant difference in use between non-Hispanic white adults and non-Hispanic black adults (6.5%).