Embargoed ISSUE BRIEF until Tuesday, December 17 at 10:00 AM ET Pain in the Nation Update: WHILE DEATHS FROM ALCOHOL, DRUGS, AND SUICIDE SLOWED SLIGHTLY IN 2017, RATES ARE STILL AT HISTORIC HIGHS Deaths from Synthetic Opioids Continue to Rise Sharply and Suicides Are Growing at the Fastest Pace in Years More than 150,000 Americans died from alcohol- and drug-induced causes and suicide in 2017 — more than twice as many as in 1999 — according to a new analysis by Trust for America’s Health (TFAH) and Well Being Trust (WBT) of mortality data from the U.S. Centers for Disease Control and Prevention (CDC).1 From 2016 to 2017, the combined death While at historically high levels, the increase rate for alcohol, drug, and suicide increased is lower than the prior two years, when there 6 percent, from 43.9 to 46.6 deaths per were 11 percent and 7 percent rises for 2015 100,000 people. to 2016 and 2014 to 2015, respectively. Annual Deaths from Alcohol, Drugs, and Suicide in the United States, 1999–2017 160000 151,845 150000 140000 130000 120000 110000 100000 90000 80000 73,990 64,591 70000 60000 47,173 50000 40000 29,199 30000 19,469 35,823 20000 MARCH 2019 19,128 10000 0 2017 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Total Deaths Drug Deaths Suicide Deaths Alcohol Deaths Source: Trust for America’s Health and Well Being Trust analysis of data from National Center For Health Statistics, CDC The trends are worse for certain groups of Americans and in certain areas: Percent Increase in Annual Rate of Death from Alcohol, Drugs, and Suicide, 2000–2017 l mong those age 35-54, the rate of A 12% death by alcohol, drug, and suicide was 72.4 per 100,000. 10% l or all males, the rate was 68.2 deaths F 8% per 100,000. 6% l egionally, 91 West Virginia residents R 4% and 77 New Mexico residents per 100,000 died from alcohol, drugs, and 2% suicide. On the low end, 31.5 Texas 0% 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 residents and 34.1 Mississippi residents per 100,000 died from alcohol, drugs, Source: Trust for America’s Health and Well Being Trust analysis of data from National Center For Health and suicide. Statistics, CDC Increasing Suicide Rate Synthetic Opioids l S ynthetic-opioid deaths were The United States also saw deaths from Synthetic-opioid deaths increased 10- concentrated in the Northeast and suicide increase more than it has since fold over the prior five years, including Midwest, while the West had relatively 1999, rising 4 percent between 2016 a 45 percent climb between 2016 and low rates.3 and 2017 (from 13.9 to 14.5 deaths per 100,000). Over the past decade 2017.2 In fact, Americans are now dying Over the past two years, TFAH and (2008–2017), suicide rates increased 22 at a faster rate from overdoses involving WBT have released a series of Pain in percent. The analysis finds that: synthetic opioids than they did from the Nation reports that track the dire all drugs in 1999 (8.7 synthetic-opioid consequences of America’s alcohol, l T he increases in deaths by suicide deaths per 100,000 in 2017 versus 6.9 drug, and suicide epidemics; share over the past decade (2008–2017) drug deaths per 100,000 in 1999). In promising practices and policy solutions; were driven by increases in suicides addition, the analysis found that: and call on the nation to come together by suffocation/hanging (42 percent l P opulations dying from synthetic to support comprehensive prevention increase) and firearms (22 percent opioids were somewhat different policies and a National Resilience increase). Poisoning/overdose and other from the populations affected by Strategy to forestall future crises. methods of suicide remained steady. other types of opioids, which were This brief, the latest in the series, covers l T hese increases were geographically more predominant in the opioid the most recent developments in the widespread but proportionally higher epidemic earlier in this decade. In synthetic-opioid crisis; the escalating among younger people (particularly 2017, synthetic-opioid deaths were rise in suicides; and the continued long- adolescents), Blacks, and Latinos. highest among males, Blacks, Whites, term climb in deaths by alcohol, drug, Absolute suicide rates remained adults ages 18–54, and those living and suicide across demographic groups highest among males, Whites, and in urban areas while the populations and geography based on CDC mortality those living in rural areas. affected earlier in the decade data. This brief also highlights key trended comparatively more White, recommendations to stem the current older, and rural. epidemic and avert future crises.4 2 TFAH • WBT • PaininTheNation.org Change in Synthetic Opioid Deaths per 100,000 2016 – 2017 and 2012 – 2017 10X 45% 2016-2017 Higher 2012-2017 WHAT ARE OPIOIDS AND SYNTHETIC OPIOIDS? Opioids are a class of drug that have l Heroin is an illicit semi-synthetic opioid chemical compounds similar to opium that is twice as potent as morphine. poppies and interact with nerve cells l S ynthetic opioids, including fentanyl to reduce pain and produce feelings of and carfentanil, are extremely potent euphoria.5 Natural opioids are sourced opioids. Fentanyl is a medication from opium poppies, semisynthetic that is 50-100 times as potent as opioids are synthesized from naturally morphine and most frequently used occurring opium, and synthetic opioids in anesthesia. Carfentanil is 10,000 are made entirely in a lab.6 times as potent as morphine and Regular opioid use can lead to is used as a tranquilizer for large dependence, and misuse can lead to animals (such as elephants). Fentanyl overdose. Common prescription opioid 7 and carfentanil, as well as their drugs were the primary drivers of the analogs, are also produced illicitly opioid epidemic when it began a couple for recreational purposes and are of decades ago. In 2009, however, the extremely dangerous, proving deadly crisis moved toward more potent and in qminiscule amounts.8,9 illicit opioids: first heroin and then, in l Methadone is a medication used 2013, synthetic opioids. to treat individuals with opioid use The most common types of opioids disorders; it reduces withdrawal include: symptoms and cravings, and blocks highs from other opioids. Methadone l N atural/semisynthetic opioids include is a type of synthetic opioid, but is the most common prescription opioids typically grouped separately from like codeine, hydrocodone (including other synthetic opioids (including in Vicodin), oxycodone (including this report) because it is an effective OxyContin and Percocet), and morphine. treatment for opioid misuse. TFAH • WBT • PaininTheNation.org 3 Key Trends in 2017: Deaths from Synthetic Opioids and Suicide In 2017, life expectancy decreased in the United States for the third year in a row.10 This was, in part, due to increases in death rates for alcohol, drugs, and suicide. The increases in deaths from synthetic- opioid overdoses and suicide in 2017 were particularly alarming. Fentanyl and Synthetic Opioids Two decades ago, fentanyl and synthetic opioid overdose deaths per week), opioids were associated with less than and overdoses were associated with 10 percent of all drug deaths and 38 percent of all drug deaths. These resulted in fewer than 1,000 annual increases happened almost entirely in the deaths nationwide. past few years, with mortality rates from synthetic opioids jumping in five years In 2017, more than 1,000 Americans from less than one death per 100,000 in died from synthetic-opioid overdoses 2012 to 8.7 deaths per 100,000 in 2017. every two weeks (an average of 547 OPIOID AND SYNTHETIC OPIOID DEATHS PER 100,000 AND PERCENT OF DRUG DEATHS INVOLVING OPIOID AND SYNTHETIC OPIOIDS, IN 1999, 2007, 2016, AND 2017 Opioid Deaths Synthetic Opioid Deaths 1999 2007 2016 2017 1999 2007 2016 2017 Deaths % of Deaths % of Deaths % of Deaths % of Deaths % of Deaths % of Deaths % of Deaths % of Per Drug Per Drug Per Drug Per Drug Per Drug Per Drug Per Drug Per Drug 100,000 Deaths 100,000 Deaths 100,000 Deaths 100,000 Deaths 100,000 Deaths 100,000 Deaths 100,000 Deaths 100,000 Deaths Overall 2.9 42% 6.1 48% 13.1 63% 14.6 64% 0.3 <10% 0.7 <10% 6.0 29% 8.7 38% Female 1.4 33% 4.3 45% 8.4 59% 9.2 61% 0.2 <10% 0.7 <10% 3.4 24% 4.8 34% Male 4.4 46% 8.1 50% 17.9 65% 20.2 66% 0.3 <10% 0.8 <10% 8.7 31% 12.8 42% Asian 0.3 21% 0.6 28% 1.7 46% 1.8 44% <0.1 <10% <0.1 <10% 0.7 19% 1.0 24% Black 3.2 38% 3.3 45% 10.0 59% 12.3 61% 0.1 <10% 0.2 <10% 5.5 31% 8.6 41% Latino 3.1 54% 2.9 50% 6.0 62% 6.7 62% 0.1 <10% 0.2 <10% 2.6 27% 3.7 34% White 3.0 43% 7.0 50% 14.6 64% 16.2 66% 0.3 <10% 0.9 <10% 6.6 29% 9.5 39% 0-17 0.1 34% 0.4 38% 0.3 61% 0.2 52% <0.1 <10% <0.1 <10% 0.1 20% 0.1 24% 18-34 3.3 46% 8.4 56% 20.4 72% 22.6 73% 0.2 <10% 0.8 <10% 10.6 37% 15.1 49% 35-54 6.4 45% 11.7 47% 22.6 62% 25.7 64% 0.6 <10% 1.5 <10% 10.4 29% 15.4 38% 55-74 1.1 26% 4.0 40% 10.7 53% 12.0 55% 0.2 <10% 0.6 <10% 3.7 18% 5.6 26% 75+ 0.4 10% 0.8 19% 1.1 24% 1.3 28% 0.1 <10% 0.2 <10% 0.2 <10% 0.3 <10% Northeast 3.5 47% 5.7 48% 18.9 69% 20.9 69% 0.2 <10% 0.7 <10% 11.5 42% 15.7 52% Midwest 1.7 34% 5.1 44% 15.8 70% 18.3 71% 0.2 <10% 0.8 <10% 7.9 35% 12.1 47% South 2.2 37% 6.5 50% 12.2 62% 13.7 64% 0.3 <10% 0.8 <10% 5.4 27% 8.0 37% West 4.7 49% 6.8 49% 7.8 49% 8.2 50% 0.4 <10% 0.5 <10% 1.2 <10% 1.9 12% Metro 3.2 43% 6.2 48% 13.5 64% 15.1 65% 0.3 <10% 0.7 <10% 6.3 30% 9.2 40% Rural 1.3 31% 6.0 48% 10.5 56% 11.6 59% 0.3 <10% 1.0 <10% 4.1 22% 6.1 31% Source: Trust for America’s Health and Well Being Trust analysis of data from National Center For Health Statistics, CDC 4 TFAH • WBT • PaininTheNation.org These increases in synthetic opioids have touched all demographic groups Fentanyl and Synthetic Opioid Deaths as a Percent of All Drug Deaths and geographic areas—but not 1999 – 2017 uniformly. Synthetic-opioid use was highest among males (12.8 deaths per 100,000), Blacks (8.6 deaths per 100,000), Whites (9.5 deaths per 38% 100,000), adults ages 18–54 (15.2 deaths per 100,000), and those living in metro areas (9.2 deaths per 100,000). This is somewhat different from the populations affected by the opioid crisis earlier in the decade, which were disproportionately White and which had a broader urban-rural spread. As of 2017, however, these deaths affected more Blacks, younger adults, and those living in metro areas. 4% The geographic differences in synthetic- 1999 2017 opioid overdose deaths were even more disparate. By region, the Northeast had the highest opioid mortality rates, with 15.7 deaths per 100,000, followed by 12.1 DATA LIMITATIONS: WHAT DOESN’T THIS DATA TELL US ABOUT deaths per 100,000 in the Midwest, and DRUG OVERDOSES? 8.0 per 100,000 in the South. The West, meanwhile, saw just 1.9 deaths per 100,000. This brief focuses on mortality l ortality reporting policies and M from alcohol, drugs, and suicide in 2017 capacity, particularly regarding Many Western and Plains states had and other recent trends. It doesn’t identifying drug type in overdoses, relatively minimal deaths from synthetic capture local trends, what’s happened vary by state and could artificially opioids in 2017. Some of this difference in 2018, nor the full burden of these lower mortality rates for synthetic is likely due to the differences in heroin epidemics beyond mortality, such as opioids and other specific drug types. supply across the country and how easily nonfatal overdoses and substance-use it mixes with synthetic opioids: the white l verdose rates, chiefly in low O disorders. Other factors to consider powder heroin that is more common on population states, may be driven when looking at overdose data are: the East Coast is easy to mix while the by one or more outbreaks from a black tar heroin more common on the l reduction in fatal overdoses may A particularly lethal or adulterated West Coast is not.11,12 If the kinds of heroin indicate a successful harm reduction batch of illicit drugs. For example, available change and/or synthetic opioids strategy (e.g. more overdoses are roughly half of the synthetic-opioid became more common in those states, being reversed by Naloxone) but not overdose deaths in Alaska occurred in the number of synthetic-opioid deaths an improvement in underlying issues. Anchorage in a three-week period. nationally could increase substantially. TFAH • WBT • PaininTheNation.org 5 Suicide The death rate from suicide was 4 more suffocation/hanging suicides and percent higher in 2017 compared with firearm suicides. Suffocation/hanging 2016, climbing from 13.9 to 14.5 deaths suicides rose 42 percent, from 2.8 to per 100,000. This is the largest annual 4.0 deaths per 100,000, and firearm increase recorded since at least 1999 suicides rose 22 percent, from 6.0 to 7.3 (when the dataset begins). Over the deaths per 100,000. Other methods of past decade (2008–2017), suicide rates suicide, including overdose/poisoning, increased 22 percent. have held steady over the same time period (remaining between 3.0 and 3.2 The rising suicide rates over the last deaths per 100,000).13 decade (2008–2017) were largely due to Suicide Deaths per 100,000 by Suicide Method, 1999–2017 8 7 6 5 4 3 2 1 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Firearm Poisoning/overdoses Suffocation/hanging Other methods Source: Trust for America’s Health and Well Being Trust analysis of data from National Center For Health Statistics, CDC Notably, the methods of suicide that Over the past decade (2008–2017), rose also accounted for the majority of suicide increased in nearly every state suicides: firearm suicides were 51 percent (except Delaware and the District of of and suffocation/hanging suicides Columbia) and touched every region were 28 percent of total suicides—and of the country. There were substantial both are particularly lethal methods variations by demographics however— (firearm suicides prove lethal more than with larger proportional increases among 80 percent of the time, and suffocation/ younger people and racial and ethnic hanging suicides are lethal more than minorities, and continued higher rates 60 percent of the time, compared with and absolute increases among males, less than 2 percent for drug overdoses/ Whites, and those living in rural areas. poisoning and cutting).14 6 TFAH • WBT • PaininTheNation.org In particular, one of the most disturbing trends of the last decade Suicide Deaths per 100,000 by Key Demographics, 2008–2017 is the rise in deaths by suicide among 20 children and adolescents (although the 18 number and rate is still relatively low 16 compared with adults). Between 2016 14 and 2017, suicide death rates among 12 children and adolescents ages 0–17 10 increased by 16 percent (from 2.1 to 8 2.4 deaths per 100,000). 6 Suicide rates among young adults ages 4 18–34 increased 7 percent (15.9 to 17.0 2 deaths per 100,000), and rates increased 0 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2 percent for adults ages 35 and older. Asian Blacks Latinos White Metro Rural This same pattern held over the last decade (2008–2017): suicide among Source: Trust for America’s Health and Well Being Trust analysis of data from National Center For Health children and adolescents increased Statistics, CDC 82 percent (from 1.3 to 2.4 deaths per 100,000), young adults increased 36 percent (12.5 to 17.0 deaths per 100,000), Percent Change in Suicide Rates by Demographics and Geography, 2008–2017 and adults ages 35 and older increased 90% 12 percent (16.4 to 18.4 deaths per 80% 100,000).15 Over that same decade, 12,660 70% youth under age 18 died from suicide. 60% Suicide rates also increased 50% proportionally more among racial and 40% ethnic minority groups, particularly 30% among Blacks and Latinos (while still 20% remaining substantially lower than 10% White suicide rates). Suicide rates 0% among Blacks increased 9 percent o l e e k 7 4 n Ag hite h t ro ra l es 54 Ag -74 No 5+ M st st es al tin ac al al Ag 0-1 -3 ia ut et Ru ea we er m M - 7 As W 18 So La Bl 35 55 W M Ov rth Fe id es es last year (from 6.1 to 6.7 deaths per es es Ag Ag 100,000) and 30 percent over the last Source: Trust for America’s Health and Well Being Trust analysis of data from National Center For Health decade (5.1 to 6.7 deaths per 100,000), Statistics, CDC and rates among Latinos increased 5 percent last year (6.4 to 6.7 deaths per 100,000) and 36 percent over the last decade (4.9 to 6.7 deaths per 100,000). For suicide death rates by additional demographic and geographic breakdowns, see the chart on page 8. TFAH • WBT • PaininTheNation.org 7 Deaths by Alcohol, Drug, and Suicide in 2017 There were 46.6 deaths by alcohol, drugs, and suicide per 100,000 people in the United States in 2017, a 6 percent increase over 2016 and a 54 percent increase over 2007. Separate trends in deaths from alcohol, drugs, and suicide are detailed below (followed by a state-by-state analysis). ALCOHOL, DRUG, AND SUICIDE DEATHS PER 100,000 IN 1999, 2007, 2016, AND 2017, AND PERCENT CHANGE IN DEATH RATES 2007–2017 Alcohol Deaths Drug Deaths Suicide Deaths % % % Change Change Change 1999 2007 2016 2017 1999 2007 2016 2017 1999 2007 2016 2017 2007- 2007- 2007- 2017 2017 2017 Overall 7.0 7.7 10.8 11.0 43% 6.9 12.7 20.8 22.7 78% 10.5 11.5 13.9 14.5 26% Female 3.2 3.8 5.9 6.0 59% 4.4 9.5 14.2 15.1 60% 4.0 4.8 6.2 6.3 31% Male 10.9 11.8 15.9 16.2 37% 9.4 16.1 27.6 30.5 89% 17.1 18.4 21.8 22.9 25% Asian 1.3 1.6 2.1 2.4 49% 1.3 2.0 3.6 4.0 101% 5.8 5.8 6.8 6.8 18% Black 7.8 5.6 6.7 6.7 21% 8.6 10.4 17.6 21.0 103% 5.4 4.8 6.1 6.7 38% Latino 6.4 6.4 8.2 8.2 27% 5.8 5.9 9.6 10.7 82% 5.0 5.3 6.4 6.7 25% White 7.0 8.3 11.9 12.2 48% 6.9 13.9 22.9 24.7 78% 11.5 13.0 15.9 16.5 27% 0-17 <0.1 <0.1 <0.1 <0.1 n/a 0.3 0.6 0.5 0.5 n/a 1.4 1.1 2.1 2.4 113% 18-34 1.1 1.3 2.3 2.2 69% 7.2 14.9 28.3 30.9 108% 12.3 12.6 15.9 17.0 35% 35-54 12.0 12.9 15.5 15.7 22% 14.4 24.7 36.6 40.2 62% 14.1 16.7 18.6 19.1 14% 55-74 17.5 18.2 25.9 26.4 45% 4.1 10.1 20.2 21.9 116% 12.7 14.2 17.4 17.6 24% 75+ 9.3 8.3 10.1 10.0 20% 4.1 4.2 4.5 4.7 11% 18.4 16.4 18.4 18.6 14% Northeast 5.6 5.8 8.4 8.5 45% 7.4 11.9 27.6 30.4 155% 7.9 8.7 10.8 11.3 30% Midwest 5.8 6.4 10.5 10.8 68% 5.1 11.6 22.7 25.8 122% 10.0 11.3 14.4 15.1 33% South 6.7 7.0 9.5 9.7 40% 6.0 13.2 19.7 21.5 63% 11.3 12.1 14.4 15.0 24% West 9.8 11.6 14.9 15.1 30% 9.5 13.7 15.9 16.4 20% 11.8 12.8 15.0 15.5 21% Metro 6.9 7.5 10.4 10.7 42% 7.3 12.8 21.2 23.2 81% 10.1 11.0 13.2 13.7 24% Rural 7.2 8.7 12.9 13.0 50% 4.4 12.4 18.7 19.8 60% 12.6 14.2 18.4 19.4 37% Source: Trust for America’s Health and Well Being Trust analysis of data from National Center For Health Statistics, CDC 8 TFAH • WBT • PaininTheNation.org Trends in Alcohol Deaths a very large increase for a single year, it is a smaller increase than the prior Increase l I n 2017, 35,800 Americans died in suicide of alcohol-induced causes, and year, when drug deaths increased by rates among 292,400 Americans died of alcohol- an unprecedented 21 percent. Over children 0-17 induced causes over the past decade the past decade (2008–2017), the drug and Blacks (2008–2017). Note: Alcohol-induced death rate increased 79 percent. in 2017 deaths include alcohol poisoning, l D rug death rates in 2017 were liver diseases, and other diseases; it highest among males (30.5 per does not include alcohol-attributable deaths, such as alcohol-related vehicle, 100,000), Whites (24.7 per 100,000), adults ages 35–54 (40.2 per 100,000), 16% Children 10% violence, or accidental fatalities. In young adults ages 18–34 (30.9 per 0-17 Blacks this report, alcohol deaths include 100,000), and those living in the alcohol-induced causes only. Northeast (30.4 per 100,000) and l T he rate of American deaths from Midwest (25.8 per 100,000). alcohol-induced causes was 2 percent l D rug death rates were nearly higher in 2017 compared to 2016, universally higher in 2017 than 2016. increasing from 10.8 to 11.0 deaths per Groups with the largest proportional 100,000. This is the smallest increase increases were Blacks (20 percent) since 2008–2009. Over the past decade and those living in the Midwest (13 (2008–2017), the alcohol death rate percent). Over the past decade, drug increased by a total of 38 percent. deaths have more than doubled for l lcohol death rates in 2017 were highest A Asians, Blacks, young adults ages 18– among males (16.2 per 100,000), Whites 35, adults ages 55–74, and those living (12.2 per 100,000), adults ages 55–74 in the Northeast and Midwest. (26.4 per 100,000), and those living in the West (15.1 per 100,000) and in rural Trends in Deaths by Suicide areas (13 per 100,000). l I n 2017, 47,200 Americans died as a result of suicide, and 411,700 l S everal groups had slightly lower or Americans died of suicide over the steady rates of alcohol deaths in 2017 past decade (2008–2017). compared with 2016 (including young adults ages 18-to-34 years old, older l D eaths by suicide in 2017 were adults ages 75 years and older, Blacks, particularly high among males (22.9 and Latinos), and nearly all groups per 100,000), Whites (16.5 per held within 3 percent. 100,000), and those living in rural areas (19.4 per 100,000). Trends in Drug Deaths l S uicide rates in 2017 were higher than l I n 2017, 74,000 Americans died from in 2016 across certain demographic drug-induced causes, and 498,400 and geographic groups. Groups with Americans died from drug-induced the largest proportional increases causes over the past decade (2008–2017). were children ages 0–17 (16 percent l T he rate that Americans died from higher), Blacks (10 percent higher), drug-induced causes increased by 9 and young adults ages 18–34 (7 percent between 2016 and 2017, from percent higher). 20.8 to 22.7 deaths per 100,000. While TFAH • WBT • PaininTheNation.org 9 State Analysis The growth in deaths by alcohol, drugs, and suicide is geographically widespread—although rates and trends vary substantially across regions. A state-level analysis follows, and charts on page 12 have state-level data on alcohol, drug, suicide, opioid, and synthetic-opioid deaths and death rates. l eaths from alcohol, drugs, and D Mexico (31.6 per 100,000), • tates with the highest suicide S suicides. From 2016 to 2017, 43 states Montana (23.7 per 100,000), and rates in 2017 were Montana (29.6 plus the District of Columbia saw Wyoming (23.3 per 100,000). per 100,000), Wyoming (27.1 per higher rates of deaths from alcohol, 100,000), and Alaska (27 per 100,000). • States with the lowest alcohol death drug, and suicide; five states had lower • States with the lowest suicide rates in 2017 were Maryland (6.5 per rates (Massachusetts, Oklahoma, rates in 2017 were New York (8.5 100,000) and Hawaii (6.7 per 100,000). Rhode Island, Utah, and Wyoming); per 100,000) and New Jersey (8.8 and two states stayed the same (New l rug deaths. Between 2016 and 2017, 39 D per 100,000) plus the District of Hampshire and New Mexico). Two states plus the District of Columbia had Columbia (6.8 per 100,000). states (Montana and New Jersey) had higher drug death rates, nine states had increases greater than 15 percent. lower rates, and two stayed the same. l pioid overdose deaths. Between O There were seven states with increases 2016 and 2017, 29 states plus the • tates with the highest death rates S of more than 15 percent (Delaware, District of Columbia had higher for alcohol, drug, and suicide in Indiana, Maine, New Jersey, North rates of opioid deaths, and 13 states 2017 were West Virginia (91 per Carolina, Ohio, and Pennsylvania). saw lower rates. (Eight states had 100,000), New Mexico (77 per insufficient data to determine trends.) 100,000), Ohio (69.4 per 100,000), • tates with the highest drug death S There were seven states with increases Alaska (67.6 per 100,000), and New rates in 2017 were West Virginia of more than 15 percent, including Hampshire (66.0 per 100,000). (56.3 per 100,000), Ohio (45.5 per two states with increases of more than • tates with the lowest death rates S 100,000), and Pennsylvania (42.9 25 percent (New Jersey, 39 percent; for alcohol, drug, and suicide in per 100,000) as well as the District of and North Carolina, 28 percent).16 2017 were Texas (31.5 per 100,000), Columbia (46.4 per 100,000). Mississippi (34.1 per 100,000), and • tates with the lowest drug death S l ynthetic-opioid overdose deaths. S Nebraska (34.4 per 100,000). rates in 2017 were Nebraska (8.5 Between 2016 and 2017, 37 states plus per 100,000), South Dakota (9.3 per the District of Columbia saw higher l lcohol deaths. Between 2016 A rates of synthetic-opioid deaths, and 100,000), and North Dakota (9.7 and 2017, 29 states had higher two states saw lower (New Mexico and per 100,000). alcohol death rates, 19 states plus North Dakota). (The remaining 11 the District of Columbia had lower l eaths by Suicide. Between 2016 and D states did not have sufficient data to alcohol death rates, and two states 2017, 42 states plus the District of determine trends.) Thirty-three states stayed the same. Two states had an Columbia had higher suicide rates, four and the District of Columbia had increase of more than 15 percent states had lower suicide rates (Delaware, increases of more than 15 percent, (Mississippi and Montana), and one Nevada, Oklahoma, and Vermont) and including 13 states with increases of state (Rhode Island) and the District four states stayed the same (California, more than 50 percent. Arizona and of Columbia both had decreases of Colorado, New York, and Virginia). North Carolina saw synthetic-opioid more than 15 percent. Five states saw increases greater than overdose death rates more than 15 percent (Hawaii, Maine, Mississippi, double between 2016 and 2017. • tates with the highest alcohol S Montana, and South Dakota). death rates in 2017 were New 10 TFAH • WBT • PaininTheNation.org Alcohol, Drug, and Suicide (Combined) Deaths per 100,000, 1999 WA MT ME ND VT OR MN ID NH SD WI NY MA WY MI CT RI NE IA PA NJ NV OH DE UT IL IN CA MD CO WV KS MO VA DC KY NC AZ TN OK NM AR SC MS AL GA <20 >20 to ≤30 TX LA >30 to ≤40 >40 to ≤50 FL AK >50 to ≤60 HI >60 to ≤70 >70 to ≤80 >80 Source: National Center for Health Statistics, CDC Alcohol, Drug, and Suicide (Combined) Deaths per 100,000, 2017 WA MT ME ND VT OR MN ID NH SD WI NY MA WY MI CT RI NE IA PA NJ NV OH DE UT IL IN CA MD CO WV KS MO VA DC KY NC AZ TN OK NM AR SC MS AL GA <20 >20 to ≤30 TX LA >30 to ≤40 >40 to ≤50 FL AK >50 to ≤60 HI >60 to ≤70 >70 to ≤80 >80 Source: National Center for Health Statistics, CDC TFAH • WBT • PaininTheNation.org 11 ALCOHOL, DRUG, SUICIDE, OPIOID, AND SYNTHETIC-OPIOID DEATHS BY STATE IN 2017, AND PERCENT CHANGE 2016–2017 Alcohol, Drug, & Alcohol Drug Suicide Opioid* Synthetic Opioid* Suicide Combined % % % % % % 2017 2017 2017 2017 2017 2017 Change Change Change Change Change Change 2017 Deaths 2017 Deaths 2017 Deaths 2017 Deaths 2017 Deaths 2017 Deaths in Rate in Rate in Rate in Rate in Rate in Rate Deaths Per Deaths Per Deaths Per Deaths Per Deaths Per Deaths Per 2016- 2016- 2016- 2016- 2016- 2016- 100,000 100,000 100,000 100,000 100,000 100,000 2017 2017 2017 2017 2017 2017 Alabama 2,131 43.7 7% 387 7.9 -2% 960 19.7 12% 836 17.1 6% - - - - - - Alaska 500 67.6 1% 159 21.5 -13% 158 21.4 15% 200 27.0 4% 102 13.8 9% 37 5.0 ** Arizona 4,039 57.6 1% 1,228 17.5 -9% 1,628 23.2 7% 1,327 18.9 3% 927 13.2 19% 267 3.8 114% Arkansas 1,308 43.5 8% 261 8.7 -9% 481 16.0 13% 631 21.0 13% - - - - - - California 14,196 35.9 1% 5,096 12.9 0% 5,302 13.4 3% 4,312 10.9 0% 2,199 5.6 9% 536 1.4 50% Colorado 3,095 55.2 5% 1,018 18.2 10% 1,050 18.7 7% 1,181 21.1 0% 578 10.3 7% 112 2.0 54% Connecticut 1,800 50.2 9% 354 9.9 5% 1,103 30.7 10% 405 11.3 2% 955 26.6 11% 686 19.1 37% Delaware 551 57.3 9% 104 10.8 -1% 342 35.6 18% 112 11.6 -7% - - - - - - DC 425 61.2 8% 63 9.1 -23% 322 46.4 15% 47 6.8 15% 244 35.2 15% 182 26.2 38% Florida 10,766 51.3 2% 2,598 12.4 -4% 5,347 25.5 6% 3,227 15.4 1% 3,245 15.5 14% 2,126 10.1 33% Georgia 3,816 36.6 6% 848 8.1 6% 1,629 15.6 10% 1,451 13.9 2% 1,014 9.7 9% 419 4.0 50% Hawaii 514 36.0 11% 95 6.7 -2% 221 15.5 7% 227 15.9 31% 53 3.7 -31% ** ** ** Idaho 840 48.9 4% 221 12.9 -2% 264 15.4 0% 392 22.8 9% 103 6.0 -15% 22 1.3 8% Illinois 5,222 40.8 8% 1,116 8.7 0% 2,812 22.0 15% 1,474 11.5 4% 2,201 17.2 13% 1,251 9.8 38% Indiana 3,663 54.9 13% 722 10.8 2% 1,925 28.9 22% 1,092 16.4 5% - - - - - - Iowa 1,178 37.4 5% 404 12.8 6% 357 11.3 5% 479 15.2 6% 206 6.5 12% 92 2.9 58% Kansas 1,174 40.3 9% 314 10.8 9% 360 12.4 8% 553 19.0 7% 144 4.9 -2% 32 1.1 18% Kentucky 2,858 64.2 5% 484 10.9 -4% 1,662 37.3 9% 770 17.3 1% 1,160 26.0 17% 780 17.5 67% Louisiana 2,142 45.7 7% 341 7.3 5% 1,138 24.3 10% 720 15.4 6% - - - - - - Maine 864 64.7 15% 194 14.5 1% 443 33.2 20% 274 20.5 21% 360 26.9 19% 278 20.8 39% Maryland 3,239 53.5 9% 393 6.5 10% 2,296 37.9 9% 630 10.4 7% 1,985 32.8 8% 1,542 25.5 41% Massachusetts 3,594 52.4 -1% 683 10.0 -2% 2,323 33.9 -3% 682 9.9 7% 1,913 27.9 -5% 1,649 24.0 6% Michigan 5,345 53.7 8% 1,049 10.5 2% 3,034 30.5 12% 1,457 14.6 6% 2,033 20.4 15% 1,368 13.7 48% Minnesota 2,166 38.8 3% 641 11.5 -5% 825 14.8 9% 783 14.0 4% 422 7.6 5% 184 3.3 84% Mississippi 1,017 34.1 12% 214 7.2 20% 387 13.0 4% 445 14.9 16% 185 6.2 3% 81 2.7 80% Missouri 3,030 49.6 2% 556 9.1 3% 1,426 23.3 0% 1,151 18.8 1% 952 15.6 4% 618 10.1 40% Montana 671 63.9 17% 249 23.7 34% 132 12.6 -4% 311 29.6 16% - - - - - - Nebraska 661 34.4 11% 245 12.8 11% 163 8.5 11% 275 14.3 11% - - - - - - Nevada 1,733 57.8 1% 513 17.1 7% 698 23.3 1% 627 20.9 -5% 412 13.7 -1% 66 2.2 22% New Hampshire 886 66.0 0% 176 13.1 -1% 479 35.7 -4% 265 19.7 8% 424 31.6 -4% 374 27.9 2% New Jersey 4,070 45.2 22% 647 7.2 10% 2,752 30.6 28% 795 8.8 15% 1,969 21.9 39% 1,376 15.3 98% New Mexico 1,608 77.0 0% 659 31.6 -2% 515 24.7 -2% 491 23.5 4% 332 15.9 -5% 75 3.6 -4% New York 7,186 36.2 3% 1,584 8.0 1% 4,117 20.7 5% 1,696 8.5 0% 3,224 16.2 7% 2,238 11.3 36% North Carolina 4,864 47.3 15% 1,019 9.9 5% 2,515 24.5 22% 1,521 14.8 9% 1,953 19.0 28% 1,285 12.5 111% North Dakota 331 43.8 1% 111 14.7 -1% 73 9.7 -15% 154 20.4 10% 35 4.6 -35% 12 1.6 -20% Ohio 8,091 69.4 13% 1,219 10.5 6% 5,299 45.5 18% 1,740 14.9 2% 4,293 36.8 18% 3,523 30.2 53% Oklahoma 2,094 53.3 -5% 605 15.4 1% 805 20.5 -4% 756 19.2 -8% 388 9.9 -13% 102 2.6 4% Oregon 2,285 55.2 4% 879 21.2 5% 676 16.3 3% 825 19.9 6% 344 8.3 9% 85 2.1 95% Pennsylvania 8,208 64.1 11% 930 7.3 -1% 5,495 42.9 15% 2,030 15.9 3% - - - - - - Rhode Island 552 52.1 -6% 123 11.6 -17% 322 30.4 -3% 129 12.2 2% 277 26.1 -1% 201 19.0 10% South Carolina 2,454 48.8 8% 631 12.6 9% 1,052 20.9 12% 838 16.7 2% 748 14.9 18% 404 8.0 68% South Dakota 435 50.0 12% 181 20.8 13% 81 9.3 7% 191 22.0 17% 35 4.0 -17% 14 1.6 39% Tennessee 3,764 56.0 8% 804 12.0 8% 1,898 28.3 8% 1,166 17.4 4% 1,269 18.9 6% 590 8.8 48% Texas 8,909 31.5 5% 2,325 8.2 4% 3,120 11.0 4% 3,778 13.3 7% 1,458 5.2 4% 348 1.2 37% Utah 1,503 48.5 -1% 259 8.3 -8% 691 22.3 -1% 663 21.4 5% 456 14.7 -4% 92 3.0 26% Vermont 335 53.7 1% 94 15.1 -4% 145 23.2 11% 112 18.0 -5% 114 18.3 13% 77 12.3 46% Virginia 3,303 39.0 4% 696 8.2 3% 1,558 18.4 7% 1,179 13.9 0% 1,241 14.7 9% 829 9.8 27% Washington 3,621 48.9 11% 1,152 15.6 11% 1,309 17.7 6% 1,297 17.5 12% 742 10.0 3% 143 1.9 51% West Virginia 1,653 91.0 13% 264 14.5 15% 1,023 56.3 13% 393 21.6 9% 833 45.9 15% 618 34.0 43% Wisconsin 2,803 48.4 7% 780 13.5 5% 1,205 20.8 9% 926 16.0 7% 926 16.0 7% 466 8.0 61% Wyoming 352 60.8 -4% 135 23.3 -2% 72 12.4 -29% 157 27.1 10% 47 8.1 -5% 17 2.9 ** United States 151,845 46.6 6% 35,823 11.0 2% 73,990 22.7 9% 47,173 14.5 4% 47,597 14.6 12% 28,466 8.7 45% *There is variation between states in their reporting of drug type involved in overdoses that makes some state comparisons of drug-specific overdose deaths unreliable. TFAH did not analyze state-level data on opioid and synthetic opioid deaths from eight states (Alabama, Arkansas, Delaware, Indiana, Louisiana, Montana, Nebraska, and Pennsylvania) that reported the type of drug in less than 75 percent of over- dose cases in 2016 and/or 2017. Deaths from these states are included in regional and national data. ** Data unavailable for privacy reasons. Source: National Center for Health Statistics, CDC 12 TFAH • WBT • PaininTheNation.org Conclusion and Recommendations The federal response, including the Substance Use-Disorder Prevention that Four Levels of the Prevention Continuum17 Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act (Pub. L. 115-271), has tended to prioritize treatment, overdose reversal, and reducing inappropriate opioid prescribing. While critical areas of focus, these actions are mostly aimed at the supply but not curbing the need for illicit substances. In fact, little attention or resources have been devoted to early prevention TERTIARY strategies and the upstream factors fueling PREVENTION: these epidemics. Said differently, we can Lessening Harm and decrease the supply of opioids, but if we Expanding Treatment do not address the demand, we have done Access to detoxification little to stem the tide of an epidemic— and medication-assisted instead just redirecting it. treatment, Naloxone Deaths from the alcohol, drugs, and suicide are the end result of complicated SECONDARY PREVENTION: and deep-seated problems in communities Promoting Early Identification and Interventions that require long-term initiatives and Screening for mental health and substance investments in a range of policies and use disorders, social service assistance, programs. Policymakers should consider outpatient counseling the full continuum of prevention in their work: from upstream strategies focused on reducing risk factors like poverty, PRIMARY PREVENTION: Instilling Resilience and racism, and social isolation; to prevention Deterring Unhealthy Behavior Knowledge and skill-building programs in schools, alcohol pricing approaches that build resilience and and access strategies, safe storage of firearms and drugs coping-skills; to early identification of and assistance in offering substance misuse and crisis intervention; to harm reduction UPSTREAM PREVENTION: Reducing Risk Factors for individuals, and their families and and Advancing Opportunity communities, to reduce the likelihood of Early childhood education programs, Earned Income Tax Credit, devastating consequences. subsidized housing These new data reinforce the need for a multi-faceted, multi-sector response, including the healthcare, mental health, public health, education, economic development, criminal justice, family service and other sectors. TFAH • WBT • PaininTheNation.org 13 TFAH and WBT continue to call for a comprehensive approach at the national, state, and local levels to counter the alcohol, drug, and suicide epidemics, including implementation of the following key recommendations: 1. Reduce risk factors and promote These kinds of policies and programs resilience in children, families, and include rental assistance and subsidized communities by supporting policies housing programs, earned income tax and programs that reduce traumatic credits, universal pre-kindergarten, and adverse experiences—such as and parental training and support exposure to violence, unstable housing, programs. Many of these programs are and racial and ethnic discrimination— cost effective. For instance, nurse family which have the biggest long-term home visiting programs have a return impact on later substance misuse; of $5.70 for every $1 invested, and early promote better mental health; and childhood education programs have a $4 reduce economic hardship. to $12 return for every $1 invested.18,19 CASE STUDY PARTNERSHIP (NFP) works with young, low-income, first-time pregnant NURSE-FAMILY women who are not ready to take care of a child by, first, establishing a trusted relationship with a public health nurse who meets with the mother from pregnancy until the baby turns two years old. For more than 35 years, NFP has enrolled mothers early in their pregnancies and helped public health nurses continuously conduct home visits over a two-and-a-half-year period. Home visits connect first-time mothers with the care and support they need to ensure a healthy pregnancy and birth. The model has been shown to have dramatic benefits to society. For instance, when Medicaid pays for NFP services, the federal government gets a 54 percent return on its investment.20 14 TFAH • WBT • PaininTheNation.org 2. Expand substance misuse prevention and mental health programs in schools by increasing the number of schools that get training for, can screen for, and can respond to childhood trauma. In addition, schools should be supported in scaling up evidence- based life- and coping-skills programs, like the Good Behavior Game; and increasing the availability of culturally appropriate mental health and other services. Several federal programs support evidence-based prevention programs in schools that promote protective factors and reduce risk behaviors, including CDC’s Division of Adolescent and School Health. Top school substance misuse prevention programs have a $3.80 to $34 return for every $1 invested; social-emotional learning programs have an $11 for $1 return; and school violence prevention (including suicide) programs have a $15 to $81 for $1 return.21,22,23,24,25 CASELIFE SKILLS TRAINING (LST) Program is focused on middle THE STUDY past 20 years and has been found to reduce the prevalence of school students and includes a “booster” program for high tobacco, alcohol and illicit drug use relative to controls by 50 school students. LST is designed to address a wide range of to 87 percent. When combined with booster sessions, LST was risk and protective factors by teaching general, personal and shown to reduce the prevalence of long-term substance misuse social skills, along with drug resistance skills and normative by as much as 66 percent, with benefits still in place beyond education. The program has been extensively tested over the the high school years.26 3. Lower excessive alcohol use through evidence-based and holding sellers and hosts liable for serving minors. For policies, such as by increasing pricing, limiting hours and example, a 10 percent increase in the price of alcoholic density of alcohol sales; enforcing underage drinking laws; beverages is shown to reduce consumption by 7.7 percent.27 CASE STUDY SCHOOLS are designed for students recovering RECOVERY HIGH and are a way to reduce school violence while improving education from a substance use disorder as part of the continuum of attainment, typically by providing intensive therapeutic and peer- recovery care. These schools offer programs that uniquely meet the recovery support and an academic curriculum with structured education and therapeutic challenges faced by those in recovery recovery-focused programming. A study found that complete and who were struggling to succeed in traditional school settings. avoidance of alcohol or other drugs increased from 20 percent They provide an alternative to the justice system and delinquency, during the 90 days before entering the school to 56 percent after.28 4. Promote harm reduction and treatment for individual with programs; and promote clean syringe access initiatives substance-use disorders by expanding access to overdose- through exchange programs and over-the-counter sales. prevention medications—such as naloxone—to first Syringe exchange programs do not increase the rate of drug responders and to those at high risk for overdose and their use and have been found to increase safe injection practices, families and friends; expand medication-assisted treatment reduce infectious disease spread, promote substance use in new and innovative ways, like at syringe exchange treatment, and are cost-effective.29 TFAH • WBT • PaininTheNation.org 15 5. Modernize and increase access and substance use services and provider to mental health and substance use networks; and offering widespread services by aligning healthcare provider medication-assisted treatment in new reimbursement, quality measures, and and innovative ways. Special attention training towards clinical models focused is needed to address equitable access on the “Whole Health” of individuals, where treatment options and providers and prioritizing integrated delivery are not readily available, such as in rural models; expanding comprehensive areas. Some effective substance use health insurance to all Americans and treatment programs have a return of ensure parity in covered mental health $3.77 per $1 invested.30 CASE STUDYsuch as the ACCOUNTABLE HEALTH COMMUNITIES (AHC) pilot model, “Navigators” focus on bridging the gap between clinical medical care and community services. They do this by systematically identifying and addressing beneficiaries’ health-related social needs, and assessing whether establishing these linkages can reduce healthcare costs and improve quality of care and outcomes. AHCs address housing instability and quality, food insecurity, utility needs, interpersonal violence and transportation needs.31 6. Limit access to lethal means of patients and families to create safe suicide by promoting safe storage of environments. The Counseling on medications and firearms through Access to Lethal Means (CALM) model public education and laws; restricting has shown to improve medication and access to firearms for children and firearms storage behavior — with one individuals in crisis or at risk of suicide; study, focusing on parental counseling and providing education and creating for suicidal youth in the emergency protocols for health care providers, department, finding 100 percent counselors, and first responders on firearms lockup at follow-up.32 how to interact with and counsel 16 TFAH • WBT • PaininTheNation.org 7. Expand crisis intervention and support for at-risk high-risk populations—like military personnel transitioning populations, such as increasing crisis intervention services to civilian life, individuals reintegrating into the community and hotlines with ready linkages to services; boosting funding from a correctional facility, and those facing severe financial for state and local health departments to implement suicide problems. The Zero Suicide model program has shown 80 prevention programs; and creating new support systems for percent reductions in suicides.33,34 CASEZERO SUICIDE INITIATIVE is a comprehensive approach to THE STUDY hurting oneself. Providers must indicate on each patient’s improve depression care in health systems, integrating suicide medical record that they completed the screening — and when prevention into primary and behavioral health care.The model they recognize a mental health problem, assign patients to requires primary care doctors to screen every patient during appropriate care, which includes cognitive behavioral therapy, every visit with two questions: How often have you felt down in medication, group counseling or new care models such as the past two weeks? And how often have you felt little pleasure same-day psychiatric evaluations, drop-in group therapy visits, in doing things? High scores lead to further questions about and hospitalization, if necessary.35,36,37 sleep disturbances, changes in appetite and/or thoughts of 8. Address the impact of the substance misuse epidemic help care for children, and expand support for the foster on children — and the need for a multi-generational care system. Model programs have been effective in helping response that includes substance use disorder treatment mothers achieve sobriety, reduced state custody placement for parents and wrap-around services for children and of children by half and had a return on investment of $2.22 families, including grandparents and other relatives who for every $1 spent on child welfare programs.38 CASE STUDY SOBRIETY TREATMENT AND RECOVERY TEAMS is a Kentucky- Children in families served by START were half as likely based program for families with parental substance use to be placed in state custody as compared with children disorders, and issues of child abuse and/or neglect that helps in a matched control group (21 percent and 42 percent, parents achieve sobriety and keep children with parents when respectively). For every dollar spent on START, Kentucky it is possible and safe. Mothers who participated in START avoided spending $2.22 on foster care. In Kentucky, areas achieved sobriety at nearly twice the rate of mothers treated have reported that demand for the program is higher than the without START (66 percent and 37 percent, respectively). available services.39 TFAH • WBT • PaininTheNation.org 17 9. Reduce availability of illicit opioids monitoring, intervention and anti- and inappropriate prescriptions through trafficking strategies focused on heroin, responsible opioid prescribing practices fentanyl and other illicit drugs. After (such as compliance with the CDC multi-faceted initiatives to promote Guideline for Prescribing Opioids and appropriate prescribing, the rate of opioid support for high-functioning Prescription prescriptions declined annually from 2012 Drug Monitoring Programs); public to 2017—and in 2017, the prescribing rate education about misuse and safe fell to the lowest in more than 10 years.40 disposal of unused drugs; and “hotspot” CASE STUDY DRUG MONITORING PROGRAMS (PDMP) are database tools that track PRESCRIPTION dispensed controlled substances in a state. For instance, in Kentucky, mandatory requirements increased use five-fold; multiple prescriptions were reduced by more than half; and opioid prescribing was reduced by around 12 percent. In Tennessee, PDMP use increased by more than 400 percent; opioid prescribing decreased by 7 percent within one year; and patients being able to fill multiple overlapping prescriptions decreased by 31 percent.41 10. Improve data accuracy and timeliness through support and analyses at the national level and in support of additional funding for local and state health agencies local and state programs. Ensuring policymakers at the state, to bolster their capacity for medical examinations and local, and national level, as well as healthcare providers toxicological services, improve reporting of non-fatal and other critical sectors, have the best, most recent data overdoses and suicide attempts, and modernize and possible allows for faster and smarter responses to critical standardize their data system; and CDC for additional data and emerging health threats. Appendix: Data Methodology Unless otherwise referenced, data used or drug-induced and a suicide, TFAH l H eroin deaths: X40–44, X60–64, in this report are from the National removed duplicates (ICD-10 underlying X85, and Y10–14 “underlying causes Center for Health Statistics’ Multiple causes of death codes X60–65) when of death” codes plus T40.1 “multiple Cause of Death Files, 1999–2017, determining combined death totals. causes of death” code. and were accessed via the CDC Wide- l C ommon prescription opioid deaths: For deaths related to specific drugs, ranging ONline Data for Epidemiologic X40–44, X60–64, X85, and Y10–14 TFAH used ICD-10 codes as follows: Research (WONDER) Database (http:// “underlying causes of death” codes plus wonder.cdc.gov/mcd-icd10.html). l A ll opioid deaths: X40–44, X60–64, T40.2 “multiple causes of death” code. X85, and Y10–14 “underlying causes For alcohol and drug deaths, TFAH used of death” codes plus T40.0–40.4 and Note: CDC and other analyses of drug deaths the CDC’s underlying cause of death T40.6 “multiple causes of death” codes. may use a slightly narrower drug-overdose categories, “Drug/Alcohol Induced category compared with the “drug-induced l S ynthetic-opioid deaths: X40–44, Causes” and, for deaths by suicide, used cause” category used in this brief. X60–64, X85, and Y10–14 “underlying the “Injury Intent and Mechanisms” causes of death” codes plus T40.4 category. Because a small number of “multiple causes of death” code. deaths are categorized as both alcohol- 18 TFAH • WBT • PaininTheNation.org Endnotes 10 urphy SL, Xu JQ, Kochanek KD, and Arias M E. “Mortality in the United States, 2017.” 17 hese are the definitions for the four major T prevention types that TFAH uses: National Center for Health Statistics, NCHS • pstream or Primordial Prevention: U 1 ll mortality data in the brief is from the A Data Brief, no. 328, November 2018. https:// Actions and measures that inhibit National Center for Health Statistics at www.cdc.gov/nchs/products/databriefs/ the emergence and establishment of CDC, and was obtained from the WONDER db328.htm (accessed January 10, 2019). environmental, economic, social and database in December 2018. For more 11 renk RG, Pollack HA. “Addressing the F behavioral conditions, and cultural information on method, see appendix on Fentanyl Threat to Public Health”, New patterns of living known to increase the page 18. England Journal of Medicine, February 2017; risk of disease. (Definition from Dictionary 2 ethadone is grouped separately and is not M of Epidemiology, Fourth Edition.) 376:605-607; https://www.nejm.org/doi/ included in the synthetic-opioids category in • rimary Prevention: Interventions before P full/10.1056/NEJMp1615145 this brief. health effects occur, through a variety 12 hang A, Macy B. “What’s Behind C 3 s defined by the U.S. Census Bureau, the A of measures, including education and The Geographical Disparities Of Drug Northeast includes Connecticut, Maine, skill-building, policy development and Overdoses In The US.” National Public Massachusetts, New Hampshire, New Jersey, implementation, and clinical services. Radio, November 2018. https://www. New York, Pennsylvania, Rhode Island, and (Definition by TFAH.) npr.org/2018/11/29/671996727/whats- Vermont; the Midwest includes Illinois, • econdary Prevention: Screening to S behind-the-geographical-disparities-of-drug- Indiana, Iowa, Kansas, Michigan, Minnesota, identify diseases in the earliest stages, overdoses-in-the-u-s Missouri, Nebraska, North Dakota, Ohio, before the onset of signs and symptoms, South Dakota, and Wisconsin; the South 13 esearch suggests that suicide by drug R through measures such as mammography includes Alabama, Arkansas, Delaware, overdose may be undercounted due to the and regular blood-pressure testing. District of Columbia, Florida, Georgia, difficulty of understanding intent, which (Definition from CDC.) Kentucky, Louisiana, Maryland, Mississippi, means the overall suicide rate is higher • ertiary Prevention: Managing disease T North Carolina, Oklahoma, Tennessee, than official reports and the true rates and post-diagnosis to slow or stop disease Texas, South Carolina, and Virginia; and the trends of overdose/poisoning suicides need progression through measures such West includes Alaska, Arizona, California, more careful study. as chemotherapy, rehabilitation, and Colorado, Hawaii, Idaho, Montana, Nevada, screening for complications. (Definition See Rockett IRH, Caine ED, et al. “Discern- : New Mexico, Oregon Utah, Washington, from CDC.) ing Suicide in Drug Intoxication Deaths: and Wyoming. Paucity and Primacy of Suicide Notes and 18 “Benefits and Costs”, Nurse-Family 4 egal L, et al. “Pain in the Nation: The S Psychiatric History.” PLoS ONE, 13(1): Partnerships, September 2014. https:// Drug, Alcohol and Suicide Crises and Need e0190200, 2018. https://doi.org/10.1371/ www.nursefamilypartnership.org/wp- for a National Resilience Strategy”, Trust journal.pone.0190200 (accessed January content/uploads/2017/07/NFP_Benefit_ for America’s Health & Well Being Trust, 10, 2019). Cost.pdf November 2017. https://www.tfah.org/ 14 picer RS and Miller TR. “Suicide Acts in S report-details/pain-in-the-nation/ 19 Wolfe D, Hovde K, Cote-Ackah C, et al. In- 8 States: Incidence and Case Fatality Rates vest in a Strong Start for Children: A Tool- 5 Opioids.” In: Substance Abuse and Mental “ by Demographics and Method.” American kit for Donors on Early Childhood.” Center Health Services Administration, February Journal of Public Health, 90(12): 1885, 2000. for High Impact Philanthropy, University 2016. https://www.samhsa.gov/atod/opioids https://www.hsph.harvard.edu/means-mat- of Pennsylvania, 2015 http://www.impact. (accessed January 10, 2019). ter/means-matter/case-fatality (accessed upenn.edu/our-analysis/opportunities-to- January 10, 2019). 6 Narcotics (Opioids).” In: U.S. Drug “ achieve-impact/early-childhood-toolkit/ Enforcement Administration, October 2018. 15 uicide is not an official cause of death for S why-invest/what-is-the-return-on-invest- https://www.dea.gov/taxonomy/term/331 children under age 5. ment/ (accessed September 2016). (accessed January 10, 2019). 20 Benefits and Costs”, Nurse-Family “ 16 here is variation between states in their T 7 Opioids.” In: National Institute on Drug “ reporting of drug type involved in over- Partnerships, September 2014. https://www. Abuse, February 2017. https://www. doses that makes some state comparisons nursefamilypartnership.org/wp-content/ drugabuse.gov/drugs-abuse/opioids of drug-specific overdose deaths unreliable. uploads/2017/07/NFP_Benefit_Cost.pdf (accessed January 10, 2019). TFAH did not analyze state-level data on 21 iller T, Hendrie D. “Substance Abuse Pre- M opioid and synthetic opioid deaths from 8 .S. Drug Enforcement Agency. “DEA Issues U vention Dollars and Cents: A Cost-Benefit eight states (Alabama, Arkansas, Delaware, Carfentanil Warning to Police and Public.” Analysis”, DHHS Pub. No. (SMA) 07-4298. Indiana, Louisiana, Montana, Nebraska, Press Release, September 22, 2016. https:// Substance Abuse and Mental Health Ser- and Pennsylvania) that reported the type www.dea.gov/divisions/hq/2016/hq092216. vices Administration, 2008. http://www. of drug in less than 70 percent of overdose shtml (accessed January 10, 2019). samhsa.gov/sites/default/files/cost-benefits- cases in 2016 and/or 2017. Deaths from prevention.pdf (accessed September2016). 9 aburn J. “Heroin Is Being Laced With a S these states are included in regional and Terrifying New Substance: What to Know national data. 22 Belfield C, Bowden AB, Klapp A, et al. “The About Carfentanil.” Time, September 12, economic value of social and emotional 2016. http://time.com/4485792/heroin- learning.” Journal of Benefit-Cost Analysis, carfentanil-drugs-ohio/ (accessed January 6(3):508-44, 2015. 10, 2019). TFAH • WBT • PaininTheNation.org 19 23 ashington State Institute for Public W 30 os S, Mayfield J, Miller M, et al. 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