12 December 2007

The Dark Side of Prescription Drugs

There is evidence that improved mental health care can reduce the incidence of suicide. But, widespread misuse of prescrition drugs appears to be driving a dramatic increase in poisoning deaths among those in the prime of their lives.

In 1980, there were 4,331 accidental poisoning deaths in the United States. In 1990, there were 5,803. In 1995, there were 9,072. In 1998, there were 10,801. Due mostly to a change in the way deaths were categorized, in 1999, this increased to 12,186. In 2005, that had grown to 20,900 deaths from accidental poisoning. There has been a more than 50% increase in accidental poisoning deaths in the last six years. The number has quadrupled since 1980.

By comparison, 17,357 people died from homicides in 2004.

Meanwhile accidental deaths from motor vehicles, drowning, fires and firearms have all decreased significantly since 1980. Deaths from falls have increased significantly, but the increase is almost all attributable to geriatric falls as a result of an aging population many of which could equally accurately be attributable to aged related frailty and loss of coordination. Accidental deaths from other causes (particularly suffocation) have also risen greatly, but these deaths are also largely a product of an aging population. About half involve people age 75 or older, and a good share of the rest involve those who are 65 years of age or older, or under 5 years of age.

In contrast poisoning deaths are heavily concentrated in people age 15 to 64 -- far more so, for example, than accidental deaths involving automobile accidents, drownings, or fires. Just 0.7% of accidental poisoning deaths involve people under the age of 15. Just 4.5% involve people aged 65 or older.

What's happening?

Unintentional deaths due to drug poisoning -- primarily with prescription drugs -- increased by 68 percent between 1999 and 2004 . . . investigators at the Centers for Disease Control and Prevention report. . . in the CDC's publication Morbidity and Mortality Weekly Report [February 9, 2007].

The annual poisoning-death rate increased from 4.4 per 100,000 population in 1999 to 7.1 per 100,000 in 2004.

Of all sex, racial, and ethnic groups, the greatest increase was among non-Hispanic white females. The age group most affected was persons aged 15 to 24 years. . . . The drugs most responsible were psychotherapeutic drugs, narcotics and hallucinogens, and unspecified drugs.

In an editorial note, the CDC researchers write: "Effective response to increasing fatal drug overdoses requires strengthening regulatory measures to reduce unsafe use of drugs, increasing physician awareness regarding appropriate pharmacologic treatment of pain and psychiatric problems, supporting best practices for treating drug dependence, and potentially modifying prescription drugs to reduce their potential for abuse."

They advise that state agencies use prescription-monitoring programs to proactively identify patients who fill several prescriptions from different doctors, as well as physicians whose prescribing practices are outside the standards of appropriate medical care.

Another source based on the same report states (emphasis added, references omitted):

The increase in poisoning mortality occurred almost exclusively among persons whose deaths were coded as unintentional drug poisoning, for which the rate increased 68.3%. The rate for poisoning deaths attributed to other substances increased 1.3%. By 2004, drug poisoning accounted for 19,838 deaths, 94.7% of all unintentional poisoning deaths. Among types of drug poisoning, the greatest increases were in the "other and unspecified" drug, psychotherapeutic drug, and "narcotic and hallucinogen" drug categories. . . .

Unintentional drug poisoning mortality rates increased substantially in the United States during 1999--2004. Previous studies, using multiple cause-of-death data, have indicated that the trend described in this report can be attributed primarily to increasing numbers of deaths associated with prescription opioid analgesics (e.g., oxycodone) and secondarily to increasing numbers of overdoses of cocaine and prescription psychotherapeutic drugs (e.g., sedatives), and cannot be attributed to heroin, methamphetamines, or other illegal drugs . . . .

The findings in this report are subject to at least three limitations. First, mortality coding assigns the underlying cause of death to broad drug categories rather than to specific drugs. Second, death certificates do not reveal the circumstances of drug use. Third, determining the intent of a person who took a drug is often difficult for a coroner or medical examiner and might result in misclassification; some of these deaths might have been suicides, although not classified as such, and some deaths categorized as suicides or of undetermined intent might have been unintentional and therefore not analyzed in this study. The extent of this error is not known.

Part of the problem is people who self-medicate with illegal drugs, part of the problem is misuse of prescription drugs. Anti-depressants are the single most prescribed type of prescription drug in the United States today.

But, illegal drug use has been relatively stable. The percentage of people over the age of twelve who used an illegal drug in the last month was unchanged from 2002 to 2006 at 8.3%. The percentage of those people who had used an illegal drug other than marijuana in the last month only slightly increased in the same time period from 3.7% to 3.9%.

Three out of four people who used illegal drugs other than marijuana used prescription drugs for a non-prescribed purpose, mostly pain killers and tranquilizers. Cocaine was the most common illegal drug other than prescription drugs and cocaine overdoses accounting for 31% of ER visits involving drug misuse in 2005, while alcohol in combination with other illegal drugs accounted for another 14% of these ER visits.

This takes place against a backdrop that would suggest that opposite. Cigarette use in the last month has fallen from 38.7% of people age 12 and over in 1985, to 25.0% in 2006. Among teenagers, it has fallen almost two-thirds from about 29% to 10%.

The percentage of high school seniors who used alcohol in the last month has fallen from 72% in 1980 to 45% in 2006, and the percentage who had five or more drinks at once in the last two weeks has fallen from 41% in 1980 to 25% in 2006. Marijuana use among high school seniors has fallen from 60% in 1980 to 42% in 2006. Similar significant declines have been seen in use of inhalants, nitrates, hallucinogens, cocaine, amphetamines (including methamphetamines) and tranquilizers by high school seniors. Only opiates other than heroin have seen increased use and that has been overwhelmed by declines in other kinds of drug use. Incidentally, teen pregnancy is also at or very near an all time low.

Thus, if any of the increase in accidental poisoning deaths comes from non-prescription illegal drug use, it appears that it involves a shrinking group of hard core users who have grown more reckless.

It is possible that some suicides are misinterpreted as accidental drug overdoses. But, the evidence isn't terribly compelling. Suicides have not fallen dramatically in lockstep with increased accidental poisonings as one would expect is that hypothesis were correct. The suicide rate has overall been stable from 1980 to 2004.

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