Pubdate: Tue, 06 Jun 2017
Source: New York Times (NY)
Copyright: 2017 The New York Times Company
Source: New York Times (NY)
Author: Josh Katz


New data compiled from hundreds of health agencies reveals the extent
of the drug overdose epidemic last year.

AKRON, Ohio - Drug overdose deaths in 2016 most likely exceeded
59,000, the largest annual jump ever recorded in the United States,
according to preliminary data compiled by The New York Times.

The death count is the latest consequence of an escalating public
health crisis: opioid addiction, now made more deadly by an influx of
illicitly manufactured fentanyl and similar drugs. Drug overdoses are
now the leading cause of death among Americans under 50.

Although the data is preliminary, the Times's best estimate is that
deaths rose 19 percent over the 52,404 recorded in 2015. And all
evidence suggests the problem has continued to worsen in 2017.

Because drug deaths take a long time to certify, the Centers for
Disease Control and Prevention will not be able to calculate final
numbers until December. The Times compiled estimates for 2016 from
hundreds of state health departments and county coroners and medical
examiners. Together they represent data from states and counties that
accounted for 76 percent of overdose deaths in 2015. They are a first
look at the extent of the drug overdose epidemic last year, a detailed
accounting of a modern plague.

The initial data points to large increases in drug overdose deaths in
states along the East Coast, particularly Maryland, Florida,
Pennsylvania and Maine. In Ohio, which filed a lawsuit last week
accusing five drug companies of abetting the opioid epidemic, we
estimate overdose deaths increased by more than 25 percent in 2016.

"Heroin is the devil's drug, man. It is," Cliff Parker said, sitting
on a bench in Grace Park in Akron. Mr. Parker, 24, graduated from high
school not too far from here, in nearby Copley, where he was a
multisport athlete. In his senior year, he was a varsity wrestler and
earned a scholarship to the University of Akron. Like his friends and
teammates, he started using prescription painkillers at parties. It
was fun, he said. By the time it stopped being fun, it was too late.
Pills soon turned to heroin, and his life began slipping away from

Mr. Parker's story is familiar in the Akron area. From a distance, it
would be easy to paint Akron - "Rubber Capital of the World" - as a
stereotypical example of Rust Belt decay. But that's far from a
complete picture. While manufacturing jobs have declined and the
recovery from the 2008 recession has been slow, unemployment in Summit
County, where Akron sits, is roughly in line with the United States as
a whole. The Goodyear factories have been retooled into technology
centers for research and polymer science. The city has begun to
rebuild. But deaths from drug overdose here have skyrocketed.

In 2016, Summit County had 312 drug deaths, according to Gary
Guenther, the county medical examiner's chief investigator - a 46
percent increase from 2015 and more than triple the 99 cases that went
through the medical examiner's office just two years before. There
were so many last year, Mr. Guenther said, that on three separate
occasions the county had to request refrigerated trailers to store the
bodies because they'd run out of space in the morgue.

It's not unique to Akron. Coroners' offices throughout the state are
being overwhelmed.

In some Ohio counties, deaths from heroin have virtually disappeared.
Instead, the culprit is fentanyl or one of its many analogues. In
Montgomery County, home to Dayton, of the 100 drug overdose deaths
recorded in January and February, only three people tested positive
for heroin; 99 tested positive for fentanyl or an analogues.

Fentanyl isn't new. But over the past three years, it has been popping
up in drug seizures across the country.

Most of the time, it's sold on the street as heroin, or drug
traffickers use it to make cheap counterfeit prescription opioids.
Fentanyls are showing up in cocaine as well, contributing to an
increase in cocaine-related overdoses.

The most deadly of the fentanyl analogues is carfentanil, an elephant
tranquilizer 5,000 times stronger than heroin. An amount smaller than
a few grains of salt can be a lethal dose.

"July 5th, 2016 - that's the day carfentanil hit the streets of
Akron," said Capt. Michael Shearer, the commander of the Narcotics
Unit for the Akron Police Department. On that day, 17 people overdosed
and one person died in a span of nine hours. Over the next six months,
the county medical examiner recorded 140 overdose deaths of people
testing positive for carfentanil. Just three years earlier, there were
fewer than a hundred drug overdose deaths of any kind for the entire

This exponential growth in overdose deaths in 2016 didn't extend to
all parts of the country. In some states in the western half of the
U.S., our data suggests deaths may have leveled off or even declined.
According to Dr. Dan Ciccarone, a professor of family and community
medicine at the University of California, San Francisco, and an expert
in heroin use in the United States, this geographic variation may
reflect a historical divide in the nation's heroin market between the
powdered heroin generally found east of the Mississippi River and the
Mexican black tar heroin found to the west.

This divide may have kept deaths down in the West for now, but
according to Dr. Ciccarone, there is little evidence of differences in
the severity of opioid addiction or heroin use. If drug traffickers
begin to shift production and distribution in the West from black tar
to powdered heroin in large quantities, fentanyl will most likely come
along with it, and deaths will rise.

First responders are finding that, with fentanyl and carfentanil, the
overdoses can be so severe that multiple doses of naloxone - the
anti-overdose medication that often goes by the brand name Narcan -
are needed to pull people out. In Warren County in Ohio, Doyle Burke,
the chief investigator at the county coroner's office, has been
watching the number of drug deaths rise as the effectiveness of Narcan
falls. "E.M.S. crews are hitting them with 12, 13, 14 hits of Narcan
with no effect," said Mr. Burke, likening a shot of Narcan to "a
squirt gun in a house fire."

Early data from 2017 suggests that drug overdose deaths will continue
to rise this year. It's the only aspect of American health, said Dr.
Tom Frieden, the former director of the C.D.C., that is getting
significantly worse. Over two million Americans are estimated to be
dependent on opioids, and an additional 95 million used prescription
painkillers in the past year - more than used tobacco. "This epidemic,
it's got no face," said Chris Eisele, the president of the Warren
County Fire Chiefs' Association and fire chief of Deerfield Township.
The Narcotics Anonymous meetings here are populated by lawyers,
accountants, young adults and teenagers who described comfortable
middle-class upbringings.

Back in Akron, Mr. Parker has been clean for seven months, though he
is still living on the streets. The ground of the park is littered
with discarded needles, and many among the homeless here are current
or former heroin users. Like most recovering from addiction, Mr.
Parker needed several tries to get clean - six, by his count. The
severity of opioid withdrawal means users rarely get clean unless they
are determined and have treatment readily available. "No one wants
their family to find them face down with a needle in their arm," Mr.
Parker said. "But no one stops until they're ready."

About the data

Our count of drug overdoses for 2016 is an estimate. A precise number
of drug overdose deaths will not be available until December.

As the chief of the Mortality Statistics Branch of the National Center
for Health Statistics at the C.D.C., Robert Anderson oversees the
collection and codification of the nation's mortality data. He noted
that toxicology results, which are necessary to assign a cause of
death, can take three to six months or longer. "It's frustrating,
because we really do want to track this stuff," he said, describing
how timely data on cause of death would let public health workers
allocate resources in the right places.

To come up with our count, we contacted state health departments in
all 50 states, in addition to the District of Columbia, asking for
their statistics on drug overdose deaths among residents. In states
that didn't have numbers available, we turned to county medical
examiners and coroners' offices. In some cases, partial results were
extrapolated through the end of the year to get estimates for 2016.

While noting the difficulty of making predictions, Mr. Anderson
reviewed The Times's estimates and said they seemed reasonable. The
overdose death rate reported by the N.C.H.S. provisional estimates for
the first half of 2016 would imply a total of 59,779 overdose deaths,
if the death rate remains flat through the second half of the year.
Based on our reporting, we believe this rate increased.

While the process in each state varies slightly, death certificates
are usually first filled out by a coroner, medical examiner or
attending physician. These death certificates are then collected by
state health departments and sent to the N.C.H.S., which assigns
what's called an ICD-10 code to each death. This code specifies the
underlying cause of death, and it's what determines whether a death is
classified as a drug overdose.

Sometimes, the cases are straightforward; other times, it's not so
easy. The people in charge of coding each death - called nosologists -
have to differentiate between deaths due to drug overdose and those
due to the long-term effects of drug abuse, which get a different
code. (There were 2,573 such deaths in 2015.) When alcohol and drugs
are both present, they must specify which of the two was the
underlying cause. If it's alcohol, it's not a "drug overdose" under
the commonly used definition. Ideally, every medical examiner, coroner
and attending physician would fill out death certificates with perfect
consistency, but there are often variations from jurisdiction to
jurisdiction that can introduce inconsistencies to the data.

These inconsistencies are part of the reason there is a delay in drug
death reporting, and among the reasons we can still only estimate the
number of drug overdoses in 2016. Since we compiled our data from
state health departments and county coroners and medical examiners
directly, the deaths have not yet been assigned ICD-10 codes by the
N.C.H.S. - that is, the official underlying cause of death has not yet
been categorized. In addition, the mortality data in official
statistics focuses on deaths among residents. But county coroners
typically count up whichever deaths come through their office,
regardless of residency. When there were large discrepancies between
the 2015 counts from the C.D.C. and the state or county, we used the
percent change from 2015 to calculate our 2016 estimate.

We can say with confidence that drug deaths rose a great deal in 2016,
but it is hard to say precisely how many died or in which places drug
deaths rose most steeply. Because of the delay associated with
toxicology reports and inconsistencies in the reported data, our exact
estimate - 62,497 total drug overdose deaths - could vary from the
true number by several thousand.
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