How Prescription Opiate Overdose Data is Collected– Part 3.2

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Liberalizing the Weaponization Process

By R Carter

Between 2010 and 2014 there was a focused effort in government and healthcare to broaden efforts to collect data related to opiate poisoning deaths. It was well known that the use of death certificates lacked details and there was no real way to enforce appropriate use. Changing that system to better collect data on opiate poisoning would cost billions of dollars and take more than a decade. With a crisis at hand, officials came up with some rapid response short cuts to improve data collection.

Data sources which were previously used only for identifying poisoning were now being combined with death certificate data to provide a more complete picture on morbidity and mortality from drug overdoses.

Data from National Poison Data System, DAWN (Drug Abuse Warning Network) administered by the Substance Abuse and Mental Health Administration and the NIS Database (National Inpatient Survey) are some sources used to enhance data collection efforts. Using diagnosis codes judgment calls were made on whether or not a death recorded in CDC Wonder, was in fact an opiate overdose death.

As covered in Part 1 and Part 2, the certifier usually a primary care provider, has filled out a death certificate with inconclusive data. In an effort to identify deaths which are or might be might be opiate related, the CDC cross references data from these other sources and flags them as opiate related. To my knowledge there are no detailed public records on how this is done, so it is impossible to peer review this process.

Like death certificates these sources usually don’t differentiate legal opiates from illegal opiates. As such, heroin, fentanyl, carfentanyl, hydrocodone, oxycodone and others, are all grouped together under one total, opiates. For this reason, data going into CDC Wonder also makes no distinction between illegal or legal opiates.

This inherent flaw can only be overcome by accessing data from other sources which are not correlated with deaths from death certificate data. Research which makes claims about prescription opiates, citing only CDC source data, may in fact be speculating on legal vs illegal sources of opiates. And for research which cites statistics based on the number of prescriptions written, there is no way to correlate this data with actual deaths. Further complicating the collection of empirical data is the fact that some clinics, known as pill mills, were deliberately over prescribing. That combined with thefts from drug manufactures and lost shipments from distribution centers, makes it impossible to accurately know to what extent, legally prescribed opiates for chronic pain play in overdose deaths.

Despite these short comings its well known the number of legal prescriptions written between 1991 and 2010 more than doubled and based on reliable research, sometimes these scripts were diverted or procured illegally. Still, the exact numbers are not known and can’t be quantified on a large scale.

Widening the Scope of Weaponization

In 2009, In a large part due to the growing opiate crisis, the Injury Surveillance Workgroup 7, began its efforts to redefine the definition of poisoning. The end results was a publication Consensus Recommendations for National and State Poisoning Surveillance. From their work they made this definition of a poison.

A poisoning is an exposure to any extrinsic substance by ingestion, inhalation, injection, or absorption through the skin or mucous membranes that results in at least one related adverse clinical effect”

They go on to clarify.

“Both a ‘poison’ and a ‘poisoning’ are difficult concepts to define. No universally accepted definitions of poisoning exist, as noted by the 2004 Institute of Medicine report, ‘Forging a Poison Prevention and Control System’. The definition proposed here is the ISW7 consensus definition designed for use in public health surveillance. Other definitions might be more useful or preferred for other fields of specialization.

The simplest approach, defining ‘poisonous’ as an inherent characteristic of a substance, is not helpful given that any substance can be toxic if given [or] consumed in a high enough dose. A quotation from Paracelsus is frequently cited to support this fact: ‘All things are poison and not without poison; only the dose [amount] makes a thing not a poison’.

Therefore, a poison is best defined not by what it is, but by what it has done in certain circumstances.

When you read a headline about opiate overdoses and deaths, we are talking about poisoning. More importantly, we are talking about a sequence of events which can’t be easily separated from their dependent causes. Therefore, a headline which lists opiates as the cause for death can only be confirmed as such by a detailed analysis of the research methods and source data.

An example of Weaponized Data in Research

The research article, “Changing dynamics of the drug overdose epidemic in the United States from 1979 through 2016” makes this quote from it research rationale.

At present, there are no reliable methods to forecast the likely future course of the epidemic. We focused on deaths from overdoses as a “relatively” [quotes added by me] reliable metric of the epidemic because all deaths are required to be reported in all U.S. states and territories using the standardized International Classification of Diseases [a death certificate]. In an effort to understand the epidemic dynamics and perhaps predict its future course, we analyzed records of 599,255 deaths from 1979 through 20161 from the National Vital Statistics System [CDC Wonder Database] where unintentional drug poisoning was identified as the main cause of death. We examined the time course of the overall number of deaths; the contributions of individual drugs (prescription opioids, heroin, synthetic opioids like fentanyl, methadone, cocaine, methamphetamine) …

What’s important to note in this example is what the researcher isn’t reporting about their assumptions which explains why death numbers are so high in this report.

The second reason for high opioid overdose rates is because most overdose deaths include multiple drugs, as many as six. It is a well known fact that the majority of heroin purchased on the street is cut with Fentanyl. Fentanyl is cheaper than heroin, one hundred times more potent and therefore it’s advantageous for drug pushers to cut their products with this substance. They use it in cutting Cocaine, Hydrocodone, OxyCodone, Methamphetamine, Psychedelics and dust it onto marijuana. Therefore when performing toxicological testing, Fentanyl shows up in a number of drug overdose deaths even though it may not be the primary drug which caused death.

This is problematic when compiling overdose deaths from a death certificate as stated by CDC.

Drug overdose deaths may involve multiple drugs; therefore, a single death might be included in more than one category when describing the number of drug overdose deaths involving specific drugs. For example, a death that involved both heroin and fentanyl would be included in both the number of drug overdose deaths involving heroin and the number of drug overdose deaths involving synthetic opioids other than methadone.

This is in essence, double dipping, even triple dipping or more when you consider the drugs which most often appear on a single overdose victim, which are, Heroin, Fentanyl, Cocaine, Methamphetamine and Alcohol.

Although the CDC makes this abundantly clear, such information is rarely if ever reported by the media. Doing so would detract from the dramatic headlines which are used.

Codes used for reporting from CDC Wonder

Below are the codes which must be entered into CDC Wonder in order to pull data on opiate related deaths.

On the CDC website it is impossible to separate codes X40-44, only X42 is appropriate for use when researching opiates. Still it is impossible to distinguish between illegal vs legal opiates. We must assume or confirm if possible, a researcher performs these tasks locally or has access to an interface at the CDC not provided to the general public for more granular searches.

For the previous example, of the 49 references cited in that publication, there is no way to confirm the methodology used or the data sources. These are some of the reasons why it becomes difficult sort out the reliability of policy created by government agencies and also why it becomes so easy to take information out of context for ideological purposes.

Point to remember when citing CDC data
  • The CDC did not collect death certificate data from all 50 states for an 8 year period between 1996 – 2003.
  • Unintentional poisoning data does not differentiate specific types of opiates as the cause and includes substance other than opiates. Within CDC Wonder codes X40-44, for “Unintentional Overdose” includes these groups:
    • X40 -Accidental poisoning by and exposure to nonopioid analgesics, antipyretics and antirheumatics, which includes:
      • 4-aminophenol derivatives
      • nonsteroidal anti-inflammatory drugs [NSAID]
      • pyrazolone derivatives
      • salicylates
    • X41- Accidental poisoning by and exposure to antiepileptic, sedative-hypnotic, antiparkinsonism and psychotropic drugs, not elsewhere classified, which includes:
      • antidepressants
      • barbiturates
      • hydantoin derivatives
      • iminostilbenes
      • methaqualone compounds
      • neuroleptics
      • psychostimulants
      • succinimides and oxazolidinediones
      • tranquilisers
    • X42 – Accidental poisoning by and exposure to narcotics and psychodysleptics [hallucinogens], not elsewhere classified, which includes:
      • cannabis (derivatives)
      • cocaine
      • codeine
      • heroin
      • lysergide [LSD]
      • mescaline
      • methadone
      • morphine
      • opium (alkaloids)
    • X43- Accidental poisoning by and exposure to other drugs acting on the autonomic nervous system, which includes:
      • parasympatholytics [anticholinergics and antimuscarinics] and spasmolytics
      • parasympathomimetics [cholinergics]
      • sympatholytics [antiadrenergics]
      • sympathomimetics [adrenergics]
    • X44- Accidental poisoning by and exposure to other and unspecified drugs, medicaments and biological substances, which includes:
      • agents primarily acting on smooth and skeletal muscles and the respiratory system
      • anaesthetics (general)(local)
      • drugs affecting the:
      • cardiovascular system
      • gastrointestinal system
      • hormones and synthetic substitutes
      • systemic and haematological agents
      • systemic antibiotics and other anti-infectives
      • therapeutic gases
      • topical preparations
      • vaccines
      • water-balance agents and drugs affecting mineral and uric acid metabolism
  • All of the codes below are useful when searching CDC Wonder for opiate overdose deaths. They’re for those who want to run their own reports and fact check reports they read. At best they can only be used for broad general grouping.
    • All classes of drug poisonings include
    • (X40-44) Overdose Unintentional
    • (X60-64) Overdose Suicide
    • (X85) D3 Drug poisonings (overdose) Homicide
    • (Y10-Y14) Drug poisonings (overdose) Undetermined

If we take a researchers intent literally, then making a claim specifically for prescription opiate overdose deaths, is an obvious misrepresentation of the actual data.

For this reason, readers should remain skeptical when reading headlines which point a finger at prescription opiates as the cause for opiate overdose deaths. Especially in light of reports from other sources at a state level which clearly show a decrease in the number of prescriptions written since 2004 or earlier. Research papers which make bold claims about the number of opiate related deaths and how prescription opiates are a leading cause must make more of an effort to be transparent with their data sources and methodologies in order be above reproach.

Anyone can use the codes on CDC Wonder to run their own reports.

At a minimum the information in this post will educate those who want to fact check others by asking questions about how and from where they get their data when reporting opiate overdose deaths.

Confirmation from Other Sources

While researching this topic I came across other publishers with similar results and concerns. This paper by Jeffrey Miron, Greg Sollenberger, and Laura Nicolae, “Overdosing on Regulation: How Government Caused the Opioid Epidemic” argue the message we see so often in research papers “More Prescribing, More Deaths” and make a case for “More Restrictions, More Deaths”. That publication is far more detailed and better documented than this post, and I encourage the reader to follow the link.

When you look at all the opportunities which exist in our system to distort the truth, take information out of context and weaponize it for ideological purpose, is it any wonder the debate goes on and the general public, like cattle led by the nose, are brain washed into believing whatever the reports tell them. As in this example found at the conclusion of my research from the American Physical Therapy Association, More Than Half of Opioid Overdose Deaths Linked to Chronic Pain Diagnoses. Organizations such as this make extreme claims which they don’t support with anything more than a single article from a source which can’t be confirmed. Such efforts are clearly exploitive to encourage the associations primary interests, that of physical therapy.