Highlights from the 2018 Annual Surveillance Report of Drug-Related Risks and Outcomes — United States Background

Surveillance Report

These slides contain selected data from the second annual surveillance report summarizing the latest information at the national level for prescribing patterns, drug use, and nonfatal and fatal overdose related to the current drug overdose epidemic.

Intended to serve as a resource for persons charged with addressing this ongoing national crisis.

Suggested citation when using resources from this presentation: Centers for Disease Control and Prevention. 2018 Annual Surveillance Report of Drug-Related Risks and Outcomes — United States. Surveillance Special Report. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Published August 31, 2018. Accessed [date] from www.cdc.gov/drugoverdose/pdf/pubs/2018-cdc-drug- surveillance-report.pd f Data Sources

Outcome Data Source Year(s)

Opioid prescribing practices IQVIA™ 2006–2017

Drug use, misuse, substance use disorder, National Survey on Drug Use and Health 2016 and treatment (NSDUH) a

Nonfatal overdose hospitalizations and Healthcare Cost and Utilization Project 2015 emergency department visits (HCUP) b

National Vital Statistics System (NVSS), Drug overdose mortality 1999–2016 Mortality Component c

aA product of the Substance Abuse and Mental Health Services Administration (SAMHSA). bA product of the Agency for Healthcare Research and Quality (AHRQ). cMaintained by the National Center for Health Statistics, CDC. Opioid Prescribing Practices Opioid Prescribing Practices

Total number and rate of opioid prescriptions a (Rx) dispensed per 100 persons annually — United States, 2017

Opioid prescriptions (Rx) Number Rate b

All opioids 191,146,822 58.5

LA/ER opioids c 17,442,895 5.3

Days of supply per Rx

< 30 days 110,759,830 33.9

≥ 30 days 80,386,991 24.6

Average opioid Rx per patient 3.4

Average days of supply per Rx 18.3

Source: IQVIA™ Transactional Data Warehouse. Abbreviation: Rx, prescription. aOpioid prescriptions, including codeine, fentanyl, hydrocodone, hydromorphone, methadone, morphine, oxycodone, oxymorphone, propoxyphene, tapentadol, tramadol, and Butrans® and Belbuca® (buprenorphine), were identified using the National Drug Code. bRate per 100 persons. cLA/ER represents opioids that are long acting (LA) or extended release (ER). Opioid Prescribing Practices

Total number and rate of morphine milligram equivalents (MME) dispensed per 100 persons annually — United States, 2017

Morphine milligram equivalents (MME) Number Rate a Total MME 166,941,732,435 MME per capita 511.1 Average MME per Rx 873.4 Average daily MME per Rx 45.3 Daily dosage per Rx < 50 MME 142,842,185 43.7 ≥ 50 but < 90 MME 32,079,439 9.8 ≥ 90 MME (high dose) 16,225,198 5.0

Source: IQVIA™ Transactional Data Warehouse. Abbreviation: MME, morphine milligram equivalents; Rx, prescription. aRate per 100 persons. Opioid Prescribing Practices

Percent of persons who had at least one prescription filled for an opioid a by sex — United States, 2017

25.0

19.9 20.0

14.8 15.0 Percent

10.0

5.0

0.0 Male Female

Source: IQVIA™ Total Patient Tracker, 2017 Enhanced. aOpioid prescriptions, including codeine, fentanyl, hydrocodone, hydromorphone, methadone, morphine, oxycodone, oxymorphone, propoxyphene, tapentadol, tramadol, and Butrans® and Belbuca® (buprenorphine), were identified using the National Drug Code. Opioid Prescribing Practices

Percent of persons who had at least one prescription filled for an opioid a by age group — United States, 2017

30.0 26.3 26.8 25.0 23.1 20.5 20.0 17.3 17.4 Percent 15.0 13.0 10.4 10.0

5.0 1.7 0.0 0–14 15–19 20–24 25–34 35–44 45–54 55–64 ≥ 65 All ages Age Group (years)

Source: IQVIA™ Total Patient Tracker, 2017 Enhanced. aOpioid prescriptions, including codeine, fentanyl, hydrocodone, hydromorphone, methadone, morphine, oxycodone, oxymorphone, propoxyphene, tapentadol, tramadol and Butrans® and Belbuca® (buprenorphine), were identified using the National Drug Code. Opioid Prescribing Practices

Annual opioid a prescribing rates overall and for high dosage prescriptions b (≥ 90 MME/day) c — United States, 2006–2017

90.0 Overall 80.0 70.0 Temporal trends c Overall 60.0 2006–2010 Prescribing rate 50.0 2010–2014 per 100 persons 2014–2017 40.0 High Dosage 30.0 2006–2009 20.0 2009–2017 High Dosage 10.0 0.0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Year

Source: IQVIA™ Transactional Data Warehouse. aOpioid prescriptions, including codeine, fentanyl, hydrocodone, hydromorphone, methadone, morphine, oxycodone, oxymorphone, propoxyphene, tapentadol, tramadol and Butrans® and Belbuca® (buprenorphine), were identified using the National Drug Code. bHigh dosage prescriptions were defined as opioid prescriptions resulting in a daily dosage of ≥ 90 morphine milligram equivalents. cTemporal trends from 2006 to 2017 were evaluated by applying joinpoint regression methodology. This modeling approach simultaneously identified statistically significant trends as well as shifts in trends that occurred within a time series. A maximum of two joinpoints was allowed. Different dash types correspond to year groupings as determined by joinpoint regression. Opioid Prescribing Practices

Annual opioid a prescribing rates by days of supply per prescription b — United States, 2006–2017

60.0 < 30 days 50.0 Temporal trends b < 30 days 40.0 2006–2010 2010–2014 ≥ 30 days 2014–2107 30.0 Prescribing rate per 100 persons ≥ 30 days 20.0 2006–2010 2010–2015 2015–2017 10.0

0.0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Year

Source: IQVIA™ Transactional Data Warehouse. aOpioid prescriptions, including codeine, fentanyl, hydrocodone, hydromorphone, methadone, morphine, oxycodone, oxymorphone, propoxyphene, tapentadol, tramadol and Butrans® and Belbuca® (buprenorphine), were identified using the National Drug Code. bTemporal trends from 2006 to 2017 were evaluated by applying joinpoint regression methodology. This modeling approach simultaneously identified statistically significant trends as well as shifts in trends that occurred within a time series. A maximum of two joinpoints was allowed. Different dash types correspond to year groupings as determined by joinpoint regression. Opioid Prescribing Practices

Average daily morphine milligram equivalents (MME) per opioid a prescription b — United States, 2006–2017

70.0

60.0

50.0 Temporal trends b

Average MME 40.0 2006–2010 per day 2010–2013 30.0 2013–2017

20.0

10.0

0.0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Year

Source: IQVIA™ Transactional Data Warehouse. aOpioid prescriptions, including codeine, fentanyl, hydrocodone, hydromorphone, methadone, morphine, oxycodone, oxymorphone, propoxyphene, tapentadol, tramadol and Butrans® and Belbuca® (buprenorphine), were identified using the National Drug Code. bTemporal trends from 2006 to 2017 were evaluated by applying joinpoint regression methodology. This modeling approach simultaneously identified statistically significant trends as well as shifts in trends that occurred within a time series. A maximum of two joinpoints was allowed. Different dash types correspond to year groupings as determined by joinpoint regression. Opioid Prescribing Practices

Average days of supply per opioid a prescription b — United States, 2006–2017

19.0

18.0

17.0

16.0 Temporal trends b 15.0 Average days 2006–2009 of supply 14.0 2009–2013 2013–2017 13.0

12.0

11.0

10.0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Year

Source: IQVIA™ Transactional Data Warehouse. aOpioid prescriptions, including codeine, fentanyl, hydrocodone, hydromorphone, methadone, morphine, oxycodone, oxymorphone, propoxyphene, tapentadol, tramadol and Butrans® and Belbuca® (buprenorphine), were identified using the National Drug Code. bTemporal trends from 2006 to 2017 were evaluated by applying joinpoint regression methodology. This modeling approach simultaneously identified statistically significant trends as well as shifts in trends that occurred within a time series. A maximum of two joinpoints was allowed. Different dash types correspond to year groupings as determined by joinpoint regression. Drug Use, Misuse, Substance Use Disorder, and Treatment Drug Use, Misuse, Substance Use Disorder, and Treatment

Self-reported prevalence of illicit drug use and prescription drug misuse a in the past year, persons 12+ years old — United States, 2016

16.0 13.9 14.0 Prescription pain relievers 12.0 Prescription tranquilizers 10.0 Prescription stimulants Percent Prescription sedatives 8.0 Marijuana b c 6.0 Heroin 4.4 4.3 Opioids 4.0 Cocaine 2.2 2.1 1.9 2.0 Methamphetamine 0.6 0.4 0.5 0.0 Substance1 Category

Source: 2016 National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration. Rockville, MD. aMisuse of prescription drugs is defined as use in any way not directed by a doctor, including use without a prescription of one’s own medication; use in greater amounts, more often, or longer than told to take a drug; or use in any other way not directed by a doctor. Prescription drugs do not include over-the-counter drugs. bMarijuana was classified as an illicit substance in NSDUH because it remains an illegal substance (Schedule I drug) under federal law. cOpioids include heroin use, prescription pain reliever misuse, or both; therefore, the numbers for heroin use and prescription pain reliever misuse do not add to those for opioid misuse because of poly-drug use. This category includes misuse of prescription fentanyl but excludes use of illicit fentanyl. Drug Use, Misuse, Substance Use Disorder, and Treatment

Self-reported prevalence of prescription drug misuse a in the past year by sex, persons 12+ years old — United States, 2016

6.0

5.0 4.8

4.0 3.8

Percent 3.0 2.2 2.3 2.3 1.9 2.0

1.0 0.5 0.6

0.0 Prescription pain relievers Prescription tranquilizers Prescription stimulants Prescription sedatives

Male Female

Self-reported prevalence of prescription drug misuse a in the past year by race/ethnicity, b persons 12+ years old — United States, 2016

5.0 4.5 4.5 4.2 4.2 3.9 3.9 4.0 3.5 3.0 2.6 2.5 Percent 2.5 2.0 1.8 1.8 1.8 1.5 1.5 1.6 1.5 1.2 1.0 0.8 0.7 0.8 0.8 0.7 0.5 0.5 0.3 0.3 0.2 0.0 Prescription pain relievers Prescription tranquilizers Prescription stimulants Prescription sedatives c White Black Hispanic American Indian/Alaska Native Native Hawaiian/other Pacific Islander Asian

Source: 2016 National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration. Rockville, MD. aMisuse of prescription drugs is defined as use in any way not directed by a doctor, including use without a prescription of one’s own medication; use in greater amounts, more often, or longer than told to take a drug; or use in any other way not directed by a doctor. Prescription drugs do not include over-the-counter drugs. bAll race/ethnicity categories other than “Hispanic” are non-Hispanic. Data on two or more races are not included. cLow precision for Native Hawaiian/other Pacific Islander race, no estimate reported. Drug Use, Misuse, Substance Use Disorder, and Treatment

Self-reported prevalence of prescription drug misuse a in the past year by age group, persons 12+ years old — United States, 2016

8.0 7.5 7.1 7.0 6.9

6.0 5.3 5.3 5.0 4.4 4.3 3.9 3.8

4.0 3.7 3.5

Percent 3.3 3.0 2.3 2.2 2.2 1.8 1.7 1.7 2.0 1.7 1.7 1.6 1.2 1.1 0.9 0.8 0.8 0.8 0.8 0.7 1.0 0.7 0.6 0.5 0.5 0.5 0.4 0.4 0.4 0.3 0.2 0.2 0.0 Prescription pain relievers Prescription tranquilizers Prescription stimulants Prescription sedatives

12–17 18–25 26–34 35–39 40–44 45–49 50–54 55–59 60–64 65+

Self-reported prevalence of prescription pain reliever misuse a in the past year by region, persons 12+ years old — United States, 2016

5.0 per 100,000 population 4.1 per 100,000 population 3.8 per 100,000 population

Self-reported prevalence of illicit drug use in the past year by sex, persons 12+ years old — United States, 2016

18.0 16.7 16.0 14.0 12.0 11.3 10.0 Percent 8.0 6.0

4.0 2.5 2.0 1.3 0.5 0.3 0.6 0.4 0.0 Marijuanaa Heroin Cocaine Methamphetamine Male Female

Self-reported prevalence of illicit drug use in the past year by race/ethnicity, a persons 12+ years old — United States, 2016

25.0

20.0 19.4 16.6

15.0 14.2 12.8

Percent 11.9 10.0 6.9

5.0 2.0 2.0 1.9 1.7 1.5 1.0 0.7 0.6 0.6 0.4 0.4 0.3 0.3 0.2 0.2 0.1 0.1 0.0 Marijuanab Heroinc Cocaine Methamphetamine

White Black Hispanic American Indian/Alaska Native Native Hawaiian/Other Pacific Islander Asian

Source: 2016 National Survey on Drug Use and Health (NSDUH). Substance Abuse and Mental Health Services Administration. Rockville, MD. aAll race/ethnicity categories other than “Hispanic” are non-Hispanic. Data on two or more races are not included. bMarijuana was classified as an illicit substance in NSDUH because it remains an illegal substance (Schedule I drug) under federal law. cLow precision for Asian race, no estimate reported. Drug Use, Misuse, Substance Use Disorder, and Treatment

Self-reported prevalence of illicit drug use in the past year by age group, persons 12+ years old — United States, 2016

35.0 33.0

30.0

25.0 22.3

20.0 Percent 15.0 14.7 12.0 11.1 10.5 10.3

10.0 9.1 7.1 5.6 3.8

5.0 3.3 1.5 1.4 1.4 1.2 0.9 0.9 0.9 0.8 0.8 0.8 0.7 0.7 0.7 0.7 0.5 0.5 0.5 0.4 0.4 0.2 0.2 0.2 0.1 0.1 0.1 0.1 0.0 0.0 c Marijuanaa Heroinb Cocaine Methamphetamine

12–17 18–25 26–34 35–39 40–44 45–49 50–54 55–59 60–64 65+

Source: 2016 National Survey on Drug Use and Health (NSDUH). Substance Abuse and Mental Health Services Administration. Rockville, MD. aMarijuana was classified as an illicit substance in NSDUH because it remains an illegal substance (Schedule I drug) under federal law. bLow precision for age 65+, no estimate reported. cPercents are rounded to the nearest tenth. Because of the rounding, some percents equal to 0.0 are displayed. These prevalence estimates are rounded down from < 0.05 percent and do not represent an absence of persons displaying a particular characteristic. Drug Use, Misuse, Substance Use Disorder, and Treatment

Self-reported prevalence of marijuana use in the past year by region, persons 12+ years old — United States, 2016

17.4 per 100,000 population 15.1 per 100,000 population 13.1 per 100,000 population 11.7 per 100,000 population

Source: 2016 National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration. Rockville, MD. Drug Use, Misuse, Substance Use Disorder, and Treatment

Self-reported prevalence of heroin use in the past year by region, persons 12+ years old — United States, 2016

0.5 per 100,000 population 0.3 per 100,000 population

Source: 2016 National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration. Rockville, MD. Drug Use, Misuse, Substance Use Disorder, and Treatment

Self-reported prevalence of cocaine use in the past year by region, persons 12+ years old — United States, 2016

2.6 per 100,000 population 2.4 per 100,000 population 1.5 per 100,000 population 1.4 per 100,000 population

Source: 2016 National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration. Rockville, MD. Drug Use, Misuse, Substance Use Disorder, and Treatment

Self-reported prevalence of methamphetamine use in the past year by region, persons 12+ years old — United States, 2016

0.8 per 100,000 population 0.5 per 100,000 population 0.4 per 100,000 population 0.2 per 100,000 population

Source: 2016 National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration. Rockville, MD. Drug Use, Misuse, Substance Use Disorder, and Treatment

Self-reported prevalence of substance use disorder a in the past year, persons 12+ years old — United States, 2016

1.6 1.5

1.4 Prescription pain relievers 1.2 Prescription tranquilizers Prescription stimulants 1.0 0.8 Prescription sedatives Percent 0.8 0.7 Marijuana 0.6 Heroin b 0.4 0.3 0.3 Opioids 0.2 0.2 0.2 Cocaine 0.2 0.1 Methamphetamines 0.0 Substance1 Category

Source: 2016 National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration. Rockville, MD. aSubstance use disorder is defined as meeting criteria for illicit or prescription drug dependence or abuse. Dependence or abuse is based on definitions found in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). bOpioids include heroin use, prescription pain reliever misuse, or both; therefore, the numbers for heroin use and prescription pain reliever misuse do not add to those for opioid misuse because of poly-drug use. This category includes misuse of prescription fentanyl but excludes use of illicit fentanyl. Drug Use, Misuse, Substance Use Disorder, and Treatment

Self-reported prevalence of illicit and prescription drug treatment a in the past year, persons 12+ years old — United States, 2016

0.9 0.8 0.8 0.7 0.6 Percent 0.5 0.5 0.4 0.3 0.2 0.1 0 Any location Specialty facility

Source: 2016 National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration. Rockville, MD. aIllicit or prescription drug treatment refers to treatment received in order to reduce or stop illicit drug use or prescription drug use, or for medical problems associated with illicit drug use or prescription drug use. It includes treatment received at any location, such as a hospital (inpatient), rehabilitation facility (inpatient or outpatient), mental health center, emergency room, private doctor's office, self-help group, or prison/jail. Illicit drug use includes the use of marijuana, cocaine (including crack), heroin, hallucinogens, inhalants, or methamphetamine. A specialty facility includes a hospital (inpatient only), rehabilitation facility (inpatient or outpatient), or mental health center. Nonfatal Overdose Hospitalizations and Emergency Department (ED) Visits Nonfatal Overdose Hospitalizations and (ED) Visits

Age-adjusted rates of drug poisoning-related hospitalizations a by selected substances — United States, 2015

120.0

100.0 96.2

Rate per 80.0 100,000 persons 60.0

40.0 23.2 20.0 16.7 5.3 5.8 1.7 4.7 0.0 All drug All opioidb Heroin Methadone Other opioidsc Cocaine Methamphetamine

Source: Weighted national estimates from Healthcare Cost and Utilization Project Nationwide Inpatient Sample, 2015, Agency for Healthcare Research and Quality. Data are from 2015, when HCUP transitioned from using ICD-9-CM to ICD-10-CM/PCM diagnosis codes and should not be compared with other years. Results may have been affected by the transition; please see the Surveillance Report technical notes for a discussion of transition. aIn-hospital deaths and patients who transferred from another hospital were excluded. Visits with missing age and gender were excluded. Numbers subject to rounding error. bFor the first three quarters of 2015, includes ICD-9-CM principal diagnosis code of 965.00, 965.01, 965.02, 965.09 or external cause of injury E850.0, E850.1, E850.2; for the fourth quarter of 2015, includes ICD-10-CM/PCS contributing causes T40.0, T40.1, T40.2, T40.3, T40.6, T40.69. cFor the first three quarters of 2015, includes ICD-9-CM principal diagnosis code of 965.00, 965.09 or external cause of injury E850.2; for the fourth quarter of 2015, includes ICD-10-CM/PCS contributing causes T40.0, T40.2, T40.4, T40.6, T40.69. Nonfatal Overdose Hospitalizations and (ED) Visits

Age-adjusted rates of drug poisoning-related hospitalizations a by selected substances and sex — United States, 2015

120.0 105.7 100.0 86.5 80.0

Rate per 60.0 100,000 persons 40.0 22.8 23.4 18.8 20.0 14.5 7.2 7.7 5.9 3.3 1.7 1.6 3.9 3.6 0.0 All drug All opioidb Heroin Methadone Other opioidsc Cocaine Methamphetamine Male Female

Source: Weighted national estimates from Healthcare Cost and Utilization Project Nationwide Inpatient Sample, 2015, Agency for Healthcare Research and Quality. Data are from 2015, when HCUP transitioned from using ICD-9-CM to ICD-10-CM/PCM diagnosis codes and should not be compared with other years. Results may have been affected by the transition; please see the Surveillance Report technical notes for a discussion of transition. aIn-hospital deaths and patients who transferred from another hospital were excluded. Visits with missing age and gender were excluded. Numbers subject to rounding error. bFor the first three quarters of 2015, includes ICD-9-CM principal diagnosis code of 965.00, 965.01, 965.02, 965.09 or external cause of injury E850.0, E850.1, E850.2; for the fourth quarter of 2015, includes ICD-10-CM/PCS contributing causes T40.0, T40.1, T40.2, T40.3, T40.6, T40.69. cFor the first three quarters of 2015, includes ICD-9-CM principal diagnosis code of 965.00, 965.09 or external cause of injury E850.2; for the fourth quarter of 2015, includes ICD-10- CM/PCS contributing causes T40.0, T40.2, T40.4, T40.6, T40.69. Nonfatal Overdose Hospitalizations and (ED) Visits

Age-adjusted rates of drug poisoning-related hospitalizations a by selected substances and age group — United States, 2015

140.0 136.9 127.5 119.4 116.3 120.0 114.6 103.7 103.5 100.0

Rate per 80.0 100,000 60.0 persons 42.4 36.3 40.0 35.7 29.5 28.7 28.2 28 26.8 24.2 18.6 15.4 15 13.2

20.0 12.3 11.5 9.1 7.8 6.6 5.9 4.0 3.3 2.8 2.3 2.2 2.3 1.4 1.3 0.8 0.7 0.6 0.4 0.1 0.0 All drug All opioidb Heroinc Methadone Other opioids d 0–14 15–19 20–24 25–34 35–44 45–54 55–64 65+

Source: Weighted national estimates from Healthcare Cost and Utilization Project Nationwide Inpatient Sample, 2015, Agency for Healthcare Research and Quality. Data are from 2015, when HCUP transitioned from using ICD-9-CM to ICD-10-CM/PCM diagnosis codes and should not be compared with other years. Results may have been affected by the transition; please see the Surveillance Report technical notes for a discussion of transition. aIn-hospital deaths and patients who transferred from another hospital were excluded. Visits with missing age and gender were excluded. Numbers subject to rounding error. bFor the first three quarters of 2015, includes ICD-9-CM principal diagnosis code of 965.00, 965.01, 965.02, 965.09 or external cause of injury E850.0, E850.1, E850.2; for the fourth quarter of 2015, includes ICD-10-CM/PCS contributing causes T40.0, T40.1, T40.2, T40.3, T40.6, T40.69. cBecause the relative standard error was > 30% or the standard error = 0 for age group 0–14, the value of the estimate was considered unreliable and was not reported. dFor the first three quarters of 2015, includes ICD-9-CM principal diagnosis code of 965.00, 965.09 or external cause of injury E850.2; for the fourth quarter of 2015, includes ICD-10-CM/PCS contributing causes T40.0, T40.2, T40.4, T40.6, T40.69. Nonfatal Overdose Hospitalizations and (ED) Visits

Age-adjusted rates of drug poisoning-related hospitalizations a by selected substances and age group — United States, 2015

14.0 13.2

12.0 9.8 10.0 9.2 9.1 7.7 8.0 7.7 Rate per 8.0 100,000 6.3 persons 6.0 5.1

4.0 3.6 3.6 1.7 2.0 1.6 0.2 0.6 0.6 0.0 Cocaine Methamphetamine 0–14 15–19 20–24 25–34 35–44 45–54 55–64 65+

Age-adjusted rates of all opioid a poisoning-related hospitalizations b by region — United States, 2015

26.1 per 100,000 population 24.4 per 100,000 population 23.8 per 100,000 population 18.9 per 100,000 population

Age-adjusted rates of heroin poisoning-related hospitalizations a by region — United States, 2015

8.4 per 100,000 population 7.4 per 100,000 population 4.0 per 100,000 population 3.1 per 100,000 population

Age-adjusted rates of methadone poisoning-related hospitalizations a by region — United States, 2015

1.9 per 100,000 population 1.8 per 100,000 population 1.6 per 100,000 population 1.5 per 100,000 population

Age-adjusted rates of cocaine poisoning-related hospitalizations a by region — United States, 2015

9.5 per 100,000 population 6.6 per 100,000 population 5.5 per 100,000 population 2.1 per 100,000 population

Age-adjusted rates of methamphetamine poisoning-related hospitalizations a by region — United States, 2015

7.7 per 100,000 population 4.6 per 100,000 population 4.1 per 100,000 population 1.7 per 100,000 population

Age-adjusted rates of drug poisoning-related emergency department visits a by selected substances — United States, 2015

180.0 174.6

160.0

140.0

120.0

Rate per 100.0 100,000 persons 80.0

60.0 44.0 40.0 25.9 17.3 20.0 1.1 3.0 5.2 0.0 All drug All opioidb Heroin Methadone Other opioidsc Cocaine Methamphetamine

Source: Weighted national estimates from Healthcare Cost and Utilization Project Nationwide Inpatient Sample, 2015, Agency for Healthcare Research and Quality. Data are from 2015, when HCUP transitioned from using ICD-9-CM to ICD-10-CM/PCM diagnosis codes and should not be compared with other years. Results may have been affected by the transition; please see the Surveillance Report technical notes for a discussion of transition. aPersons who were hospitalized, died, or transferred to another facility were excluded. Visits with missing age and gender were excluded. Numbers subject to rounding error. bFor the first three quarters of 2015, includes ICD-9-CM principal diagnosis code of 965.00, 965.01, 965.02, 965.09 or external cause of injury E850.0, E850.1, E850.2; for the fourth quarter of 2015, includes ICD-10-CM/PCS contributing causes T40.0, T40.1, T40.2, T40.3, T40.6, T40.69. cFor the first three quarters of 2015, includes ICD-9-CM principal diagnosis code of 965.00, 965.09 or external cause of injury E850.2; for the fourth quarter of 2015, includes ICD-10-CM/PCS contributing causes T40.0, T40.2, T40.4, T40.6, T40.69. Nonfatal Overdose Hospitalizations and (ED) Visits

Age-adjusted rates of drug poisoning-related emergency department visits a by selected substances and sex — United States, 2015

200.0 182.1 180.0 167.2 160.0 140.0 120.0 Rate per 100.0 100,000 persons 80.0 60.0 54.0 35.7 40.0 34.0 16.1 17.5 17.1 20.0 6.2 1.3 1.0 3.9 2.2 4.2 0.0 b c All drug All opioid Heroin Methadone Other opioids Cocaine Methamphetamine Male Female

Source: Weighted national estimates from Healthcare Cost and Utilization Project Nationwide Inpatient Sample, 2015, Agency for Healthcare Research and Quality. Data are from 2015, when HCUP transitioned from using ICD-9-CM to ICD-10-CM/PCM diagnosis codes and should not be compared with other years. Results may have been affected by the transition; please see the Surveillance Report technical notes for a discussion of transition. aPersons who were hospitalized, died, or transferred to another facility were excluded. Visits with missing age and gender were excluded. Numbers subject to rounding error. bFor the first three quarters of 2015, includes ICD-9-CM principal diagnosis code of 965.00, 965.01, 965.02, 965.09 or external cause of injury E850.0, E850.1, E850.2; for the fourth quarter of 2015, includes ICD-10-CM/PCS contributing causes T40.0, T40.1, T40.2, T40.3, T40.6, T40.69. cFor the first three quarters of 2015, includes ICD-9-CM principal diagnosis code of 965.00, 965.09 or external cause of injury E850.2; for the fourth quarter of 2015, includes ICD-10- CM/PCS contributing causes T40.0, T40.2, T40.4, T40.6, T40.69. Nonfatal Overdose Hospitalizations and (ED) Visits

Age-adjusted rates of drug poisoning-related emergency department visits a by selected substances and age group — United States, 2015

325.0 307.7 300.0 281.1

275.0 260.6 250.0 225.0 200.0 180.7 Rate per 175.0 145.8

100,000 150.0 134.5

persons 111.4

125.0 107.1 99.7 88.9

100.0 81.8 73.2

75.0 59.5 41.6

50.0 35.9 28.5 28.6 26.5 26.0 22.2 22.0 18.8 18.5 15.2 14.1 12.6 11.2

25.0 8.2 4.0 3.9 2.3 1.9 1.7 1.5 1.0 1.1 0.5 0.3 0.0 0.1 c All drug All opioid Heroinb Methadone Other opioids 0–14 15–19 20–24 25–34 35–44 45–54 55–64 65+

Source: Weighted national estimates from Healthcare Cost and Utilization Project Nationwide Inpatient Sample, 2015, Agency for Healthcare Research and Quality. Data are from 2015, when HCUP transitioned from using ICD-9-CM to ICD-10-CM/PCM diagnosis codes and should not be compared with other years. Results may have been affected by the transition; please see the Surveillance Report technical notes for a discussion of transition. aPersons who were hospitalized, died, or transferred to another facility were excluded. Visits with missing age and gender were excluded. Numbers subject to rounding error. bFor the first three quarters of 2015, includes ICD-9-CM principal diagnosis code of 965.00, 965.01, 965.02, 965.09 or external cause of injury E850.0, E850.1, E850.2; for the fourth quarter of 2015, includes ICD-10-CM/PCS contributing causes T40.0, T40.1, T40.2, T40.3, T40.6, T40.69. cFor the first three quarters of 2015, includes ICD-9-CM principal diagnosis code of 965.00, 965.09 or external cause of injury E850.2; for the fourth quarter of 2015, includes ICD-10-CM/PCS contributing causes T40.0, T40.2, T40.4, T40.6, T40.69. Nonfatal Overdose Hospitalizations and (ED) Visits

Age-adjusted rates of drug poisoning-related emergency department visits a by selected substances and age group — United States, 2015

14.0 11.8 12.0 10.3 10.0 8.3 Rate per 8.0 100,000 6.4 6.4 persons 6.0 5.1 4.7 3.8 3.9 4.0 2.9 2.0 2.0 2.0 1.2 0.7 0.4 0.4 0.0 Cocaine Methamphetamine 0–14 15–19 20–24 25–34 35–44 45–54 55–64 65+

Age-adjusted rates of all opioid a poisoning-related emergency department visits b by region — United States, 2015

77.9 per 100,000 population 56.0 per 100,000 population 32.8 per 100,000 population 27.6 per 100,000 population

Age-adjusted rates of heroin poisoning-related emergency department visits a by region — United States, 2015

58.1 per 100,000 population 36.8 per 100,000 population 15.4 per 100,000 population 10.2 per 100,000 population

Age-adjusted rates of methadone poisoning-related emergency department visits a by region — United States, 2015

1.6 per 100,000 population 1.3 per 100,000 population 1.1 per 100,000 population 0.9 per 100,000 population

Age-adjusted rates of cocaine poisoning-related emergency department visits a by region — United States, 2015

3.7 per 100,000 population 3.5 per 100,000 population 3.4 per 100,000 population 1.5 per 100,000 population

Age-adjusted rates of methamphetamine poisoning-related emergency department visits a by region — United States, 2015

6.8 per 100,000 population 6.0 per 100,000 population 5.0 per 100,000 population 2.3 per 100,000 population

Age-adjusted rates of drug overdose deaths a and drug overdose deaths involving any opioid b for all intents and for unintentional intent by year — United States, 1999–2016

20.0 18.0 16.0 14.0 12.0 Drug overdose deaths (of all Rate per intents) 100,000 10.0 persons Unintentional drug overdose 8.0 deaths 6.0 Drug overdose deaths involving any 4.0 opioid (of all intents) 2.0 Unintentional drug overdose deaths involving any opioid 0.0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Year

Source: National Vital Statistics System, Mortality File, CDC WONDER. aDeaths are classified using the International Classification of Diseases, Tenth Revision (ICD–10). All drug overdose deaths are identified using underlying cause-of-death codes X40–X44 (unintentional), X60–X64 (suicide), X85 (homicide), and Y10–Y14 (undetermined). Unintentional drug overdose deaths are identified using underlying cause-of-death codes X40–X44. Note that overall drug overdose deaths and opioid overdose deaths include deaths of any intent. In 2016, 5.7% of drug overdose deaths had undetermined intent; this is a decrease from 14.7% of drug overdose deaths that had an undetermined intent in 1999. Some of these deaths may be unintentional drug overdose deaths. bDrug overdose deaths, as defined, that involve opium (T40.0), heroin (T40.1), natural and semi-synthetic opioids (T40.2), methadone (T40.3), other synthetic opioids excluding methadone (T40.4), and other and unspecified narcotics (T40.6). Drug Overdose Mortality

Age-adjusted rates a of drug overdose deaths by drug or drug class and year — United States, 1999–2016

7.0

6.0 Synthetic opioids other than methadone b 5.0 Prescription opioids c

Rate per 4.0 100,000 Heroin persons 3.0 Cocaine 2.0

1.0 Psychostimulants with abuse potential d 0.0

Year

Source: National Vital Statistics System, Mortality File, CDC WONDER. aRate per 100,000 population age-adjusted to the 2000 U.S. standard population using the vintage year population of the data year. Because deaths might involve more than one drug, some deaths are included in more than one category. Specification on death certificates of drugs involved with deaths varies over time. In 2016, 15% of drug overdose deaths did not include information on the specific type of drug(s) involved Some of these deaths may have involved opioids or stimulants. bDrug overdose deaths that involve synthetic opioids other than methadone (T40.4). cDrug overdose deaths that involve natural and semi-synthetic opioids (T40.2) or methadone (T40.3). dDrug overdose deaths that involve psychostimulants with abuse potential (T43.6). Drug Overdose Mortality

Rates a of drug overdose deaths by drug or drug class and age group — United States, 2016

16.0

14.0 13.6 11.9 11.9

12.0 11.3 10.1 9.2 9.0 10.0 9.0 8.4

Rate per 7.7

8.0 7.0 100,000 6.1 6.0 5.7 persons 6.0 5.4 4.5 4.5 4.5 4.5 4.3 4.2 4.0 3.9

4.0 3.0 2.6 1.9 1.7

2.0 1.3 0.8 0.8 0.6 0.6 0.4 0.0 Synthetic opioids other than Prescription opioidsc Heroin Cocaine Psychostimulants with methadone b abuse potential d

15–24 25–34 35–44 45–54 55–64 ≥65

Source: National Vital Statistics System, Mortality File, CDC WONDER. aRate per 100,000 population using the vintage year population of the data year. Because deaths might involve more than one drug, some deaths are included in more than one category. Specification on death certificates of drugs involved with deaths varies over time. In 2016, 15% of drug overdose deaths did not include information on the specific type of drug(s) involved. Some of these deaths may have involved opioids or stimulants. bDrug overdose deaths that involve synthetic opioids other than methadone (T40.4). cDrug overdose deaths that involve natural and semi-synthetic opioids (T40.2) or methadone (T40.3). dDrug overdose deaths that involve psychostimulants with abuse potential (T43.6). Drug Overdose Mortality

Age-adjusted rates a of drug overdose deaths by sex — United States, 2016

10.0 8.9 9.0 8.0 7.5 7.0 6.2 Rate per 6.0 4.7 100,000 5.0 4.3 persons 4.0 3.5 3.4 3.0 2.4 1.8 2.0 1.4 1.0 0.0 Synthetic opioids other than Prescription opioidsc Heroin Cocaine Psychostimulants with methadone b abuse potential d Male Female

Source: National Vital Statistics System, Mortality File, CDC WONDER. aRate per 100,000 population age-adjusted to the 2000 U.S. standard population using the vintage year population of the data year. Because deaths might involve more than one drug, some deaths are included in more than one category. Specification on death certificates of drugs involved with deaths varies over time. In 2016, 15% of drug overdose deaths did not include information on the specific type of drug(s) involved. Some of these deaths may have involved opioids or stimulants. bDrug overdose deaths that involve synthetic opioids other than methadone (T40.4). cDrug overdose deaths that involve natural and semi-synthetic opioids (T40.2) or methadone (T40.3). dDrug overdose deaths that involve psychostimulants with abuse potential (T43.6). Drug Overdose Mortality

Age-adjusted rates a of drug overdose deaths by race/ethnicity — United States, 2016

9.0 8.2 8.0 7.0 6.9 7.0 6.5 6.3 6.1 6.0 5.6 5.0 5.0 4.5 Rate per 4.1 100,000 4.0 3.3 3.4 persons 2.8 3.0 3.0 2.7 2.1 2.1 2.0 2.0 1.5 1.2 0.7 0.8 1.0 0.6 0.5 0.4 0.0 Synthetic opioids other than Prescription opioidsc Heroin Cocaine Psychostimulants with abuse methadone b potential d

White, non-Hispanic Black, non-Hispanic Asian/Pacific Islander, non-Hispanic American Indian/Alaska Native, non-Hispanic Hispanic

Source: National Vital Statistics System, Mortality File, CDC WONDER. aRate per 100,000 population age-adjusted to the 2000 U.S. standard population using the vintage year population of the data year. Because deaths might involve more than one drug, some deaths are included in more than one category. Specification on death certificates of drugs involved with deaths varies over time. In 2016, 15% of drug overdose deaths did not include information on the specific type of drug(s) involved. Some of these deaths may have involved opioids or stimulants. bDrug overdose deaths that involve synthetic opioids other than methadone (T40.4). cDrug overdose deaths that involve natural and semi-synthetic opioids (T40.2) or methadone (T40.3). dDrug overdose deaths that involve psychostimulants with abuse potential (T43.6). Limitations

Since four distinct data sources were used, terminology and definitions were not standardized across all outcomes, and the most recent year of data varied by source. • Comparability of data across sections is limited. In the mortality section, involved drugs were not specified in approximately 20% of dru