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. 2018 Jul/Aug;133(4):423-431.
doi: 10.1177/0033354918774330. Epub 2018 Jun 27.

The Effect of Incomplete Death Certificates on Estimates of Unintentional Opioid-Related Overdose Deaths in the United States, 1999-2015

Jeanine M Buchanich  1 , Lauren C Balmert  2 , Karl E Williams  3 , Donald S Burke  4
Affiliations

The Effect of Incomplete Death Certificates on Estimates of Unintentional Opioid-Related Overdose Deaths in the United States, 1999-2015

Jeanine M Buchanich et al. Public Health Rep. 2018 Jul/Aug.

Abstract

Objectives: A complete and accurate count of the number of opioid-related overdose deaths is essential to properly allocate resources. We determined the rate of unintentional overdose deaths (non-opioid-related, opioid-related, or unspecified) in the United States and by state from 1999 to 2015 and the possible effects of underreporting on national estimates of opioid abuse.

Methods: We abstracted unintentional drug overdose deaths ( International Classification of Diseases, 10th Revision, codes X40-X44) with contributory drug-specific T codes (T36.0-T50.9) from the Mortality Multiple Cause Micro-Data Files. We assumed that the proportion of unspecified overdose deaths that might be attributed to opioids would be the same as the proportion of opioid-related overdose deaths among all overdose deaths and calculated the number of deaths that could be reallocated as opioid-related for each state and year. We then added these reallocated deaths to the reported deaths to determine their potential effect on total opioid-related deaths.

Results: From 1999 to 2015, a total of 438 607 people died from unintentional drug overdoses. Opioid-related overdose deaths rose 401% (from 5868 to 29 383), non-opioid-related overdose deaths rose 150% (from 3005 to 7505), and unspecified overdose deaths rose 220% (from 2255 to 29 383). In 5 states (Alabama, Indiana, Louisiana, Mississippi, and Pennsylvania), more than 35% of unintentional overdose deaths were coded as unspecified. Our reallocation resulted in classifying more than 70 000 unspecified overdose deaths as potential additional opioid-related overdose deaths.

Conclusions: States may be greatly underestimating the effect of opioid-related overdose deaths because of incomplete cause-of-death reporting, indicating that the current opioid overdose epidemic may be worse than it appears.

Keywords: death; death certificates; drug overdose; epidemics; opioids.

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Conflict of interest statement

Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Figures

Figure 1.
Figure 1.
Unintentional opioid-related and non–opioid-related unintentional drug overdose deaths in the United States, 1999-2015, using International Classification of Diseases, 10th Revision (ICD-10) codes X40-X44.
Figure 2.
Figure 2.
Percentage of non–opioid-related, opioid-related, and unspecified unintentional drug overdose deaths in the United States in 2015, using International Classification of Diseases, 10th Revision (ICD-10) codes T36.0-T39.9 and T40.5-T50.8 (opioid-related), T40.0-T40.4 (non–opioid-related), and T50.9 (unspecified). Sum may not equal 100.0%; a small number of X40-X44 deaths had no T36.0-T50.9 code.
Figure 3.
Figure 3.
Reallocated and reported opioid-related unintentional drug overdose deaths in the United States, 1999-2015. The numbers of reallocated opioid-related unintentional overdose deaths were estimated by reallocating such deaths from unspecified drugs according to the number of known opioid-related overdose deaths as a percentage of all unintentional drug overdose deaths during the same period.
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