Loneliness, Lack of Social and Emotional Support, and Mental Health Issues - United States, 2022.

Loneliness and lack of social connection are widespread and negatively affect physical and mental health and well-being. Data are limited for persons disproportionately affected by social disconnection, especially those who do not identify as heterosexual and cisgender. Using data from the 2022 Behavioral Risk Factor Surveillance System in 26 U.S. states, CDC examined associations of loneliness and lack of social and emotional support to mental health variables. Prevalence estimates for the mental health variables were significantly higher among adults who reported loneliness and lack of social and emotional support than among those adults who did not. The prevalence of loneliness was highest among respondents who identified as bisexual (56.7%) and transgender (range = 56.4%-63.9%). Prevalence of lack of social and emotional support was highest among those who identified as transgender female (44.8%), transgender gender nonconforming (41.4%), and those with household income below $25,000 (39.8%). Prevalences of stress, frequent mental distress, and history of depression were highest among bisexual (34.3%-54.4%) and transgender adults (36.1%-67.2%). Addressing the threat to mental health among sexual and gender minority groups should include consideration of loneliness and lack of social and emotional support. Providing access to health services that are affirming for sexual and gender minority groups and collecting data to address health inequities might help improve the delivery of culturally competent care.

Public Health Interventions and Overdose-Related Outcomes Among Persons With Opioid Use Disorder.

Importance: Given the high number of opioid overdose deaths in the US and the complex epidemiology of opioid use disorder (OUD), systems models can serve as a tool to identify opportunities for public health interventions. Objective: To estimate the projected 3-year association between public health interventions and opioid overdose-related outcomes among persons with OUD. Design, Setting, and Participants: This decision analytical model used a simulation model of the estimated US population aged 12 years and older with OUD that was developed and analyzed between January 2019 and December 2023. The model was parameterized and calibrated using 2019 to 2020 data and used to estimate the relative change in outcomes associated with simulated public health interventions implemented between 2021 and 2023. Main Outcomes and Measures: Projected OUD and medications for OUD (MOUD) prevalence in 2023 and number of nonfatal and fatal opioid-involved overdoses among persons with OUD between 2021 and 2023. Results: In a baseline scenario assuming parameters calibrated using 2019 to 2020 data remained constant, the model projected more than 16 million persons with OUD not receiving MOUD treatment and nearly 1.7 million persons receiving MOUD treatment in 2023. Additionally, the model projected over 5 million nonfatal and over 145 000 fatal opioid-involved overdoses among persons with OUD between 2021 and 2023. When simulating combinations of interventions that involved reducing overdose rates by 50%, the model projected decreases of up to 35.2% in nonfatal and 36.6% in fatal opioid-involved overdoses among persons with OUD. Interventions specific to persons with OUD not currently receiving MOUD treatment demonstrated the greatest reduction in numbers of nonfatal and fatal overdoses. Combinations of interventions that increased MOUD initiation and decreased OUD recurrence were projected to reduce OUD prevalence by up to 23.4%, increase MOUD prevalence by up to 137.1%, and reduce nonfatal and fatal opioid-involved overdoses among persons with OUD by 6.7% and 3.5%, respectively. Conclusions and Relevance: In this decision analytical model study of persons with OUD, findings suggested that expansion of evidence-based interventions that directly reduce the risk of overdose fatality among persons with OUD, such as through harm reduction efforts, could engender the highest reductions in fatal overdoses in the short-term. Interventions aimed at increasing MOUD initiation and retention of persons in treatment projected considerable improvement in MOUD and OUD prevalence but could require a longer time horizon for substantial reductions in opioid-involved overdoses.

Prevalence of Diagnosed Arthritis - United States, 2019-2021.

Arthritis includes approximately 100 conditions that affect the joints and surrounding tissues. It is a leading cause of activity limitations, disability, and chronic pain, and is associated with dispensed opioid prescriptions, substantially contributing to health care costs. Combined 2019-2021 National Health Interview Survey data were analyzed to update national prevalence estimates of self-reported diagnosed arthritis. An estimated 21.2% (18.7% age-standardized) of U.S. adults aged ≥18 years (53.2 million) had diagnosed arthritis during this time frame. Age-standardized arthritis prevalences were higher among women (20.9%) than men (16.3%), among veterans (24.2%) than nonveterans (18.5%), and among non-Hispanic White (20.1%) than among Hispanic or Latino (14.7%) or non-Hispanic Asian adults (10.3%). Adults aged ≥45 years represent 88.3% of all U.S. adults with arthritis. Unadjusted arthritis prevalence was high among adults with chronic obstructive pulmonary disease (COPD) (57.6%), dementia (55.9%), a disability (54.8%), stroke (52.6%), heart disease (51.5%), diabetes (43.1%), or cancer (43.1%). Approximately one half of adults aged ≥65 years with COPD, dementia, stroke, heart disease, diabetes, or cancer also had a diagnosis of arthritis. These prevalence estimates can be used to guide public health policies and activities to increase equitable access to physical activity opportunities within the built environment and other arthritis-appropriate, evidence-based interventions.

Arthritis Among Children and Adolescents Aged <18 Years - United States, 2017-2021.

Arthritis affects persons of all ages, including younger adults, adolescents, and children; however, recent arthritis prevalence estimates among children and adolescents aged <18 years are not available. Previous prevalence estimates among U.S. children and adolescents aged <18 years ranged from 21 to 403 per 100,000 population depending upon the case definition used. CDC analyzed aggregated 2017-2021 National Survey of Children's Health data to estimate the national prevalence of parent-reported arthritis diagnosed among children and adolescents aged <18 years. An estimated 220,000 (95% CI = 187,000-260,000) U.S. children and adolescents aged <18 years (305 per 100,000) had diagnosed arthritis. Arthritis prevalence among non-Hispanic Black or African American children and adolescents was twice that of non-Hispanic White children and adolescents. Co-occurring conditions, including depression, anxiety, overweight, physical inactivity, and food insecurity were associated with higher prevalences of arthritis. These findings highlight that children and adolescents should be prioritized for arthritis prevention and treatments by identifying risk factors for arthritis, developing self-management interventions to improve arthritis, physical activity or weight control, and screening and linking to mental health services. Health systems and payors can take steps to ensure equitable access to therapies (e.g., physical therapies and medications).

Increases in methamphetamine injection among treatment admissions in the U.S.

BACKGROUND: Prior research indicates rising methamphetamine use and harms in the U.S., potentially related to increases in methamphetamine injection. To date, research on trends and correlates of methamphetamine injection is limited. METHODS: Analysis of trends and correlates of methamphetamine injection among treatment admissions among persons aged ≥ 12 whose primary substance of use at admission is methamphetamine. Data are from the Treatment Episode Data Set. Analyses includes descriptive statistics, trend analyses, and multilevel multivariable logistic regression. RESULTS: Primary methamphetamine treatment admissions increased from 138,379 in 2010 to 201,021 in 2019. Among primary methamphetamine admissions, injection as the usual route of use increased from 24,821 (18.0 % of admissions) in 2010 to 55,951 (28.2 % of admissions) in 2019. Characteristics associated with increased adjusted odds of reporting methamphetamine injection included: males (aOR = 1.13, 95 % CI = 1.10-1.15); admission age 25-34 years (aOR = 1.23, 95 % CI = 1.19-1.28) and 35-44 years (aOR = 1.12, 95 % CI = 1.08-1.17) compared to age 18-24; dependent living (aOR = 1.33, 95 % CI = 1.29-1.37) and homelessness (aOR = 1.58, 95 % CI = 1.54-1.63) compared to independent living; part-time employment (aOR = 1.08, 95 % CI = 1.02-1.14), unemployment (aOR = 1.39, 95 % CI = 1.34-1.44) and not in labor force (aOR = 1.43, 95 % CI = 1.37-1.49) compared to full-time employment; one to ≥ four prior treatment admissions (aORs ranging from 1.19 to 1.94) compared to no prior admissions; also reporting use of cocaine (aOR = 1.10, 95 % CI = 1.05-1.16), heroin (aOR = 3.52, 95 % CI = 3.40-3.66), prescription opioids (aOR = 1.61, 95 % CI = 1.54-1.67), or benzodiazepines (aOR = 1.42, 95 % CI = 1.32-1.52) at treatment admission. CONCLUSIONS: Findings lend further evidence to a resurgence of methamphetamine use that is intertwined with the ongoing opioid crisis in the U.S. Efforts to expand evidence-based prevention, treatment, and response efforts, particularly to populations at highest risk, are urgently needed.

Vital Signs: Drug Overdose Deaths, by Selected Sociodemographic and Social Determinants of Health Characteristics - 25 States and the District of Columbia, 2019-2020.

INTRODUCTION: Drug overdose deaths increased approximately 30% from 2019 to 2020 in the United States. Examining rates by demographic and social determinants of health characteristics can identify disproportionately affected populations and inform strategies to reduce drug overdose deaths. METHODS: Data from the State Unintentional Drug Overdose Reporting System (SUDORS) were used to analyze overdose death rates from 2019 to 2020 in 25 states and the District of Columbia. Rates were examined by race and ethnicity and county-level social determinants of health (e.g., income inequality and treatment provider availability). RESULTS: From 2019 to 2020, drug overdose death rates increased by 44% and 39% among non-Hispanic Black (Black) and non-Hispanic American Indian or Alaska Native (AI/AN) persons, respectively. Significant disparities were found across sex, age, and racial and ethnic subgroups. In particular, the rate in 2020 among Black males aged ≥65 years (52.6 per 100,000) was nearly seven times that of non-Hispanic White males aged ≥65 years (7.7). A history of substance use was frequently reported. Evidence of previous substance use treatment was lowest for Black persons (8.3%). Disparities in overdose deaths, particularly among Black persons, were larger in counties with greater income inequality. Opioid overdose rates in 2020 were higher in areas with more opioid treatment program availability compared with areas with lower opioid treatment availability, particularly among Black (34.3 versus 16.6) and AI/AN (33.4 versus 16.2) persons. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Health disparities in overdose rates continue to worsen, particularly among Black and AI/AN persons; social determinants of health, such as income inequality, exacerbate these inequities. Implementation of available, evidence-based, culturally responsive overdose prevention and response efforts that address health disparities impacting disproportionately affected populations are urgently needed.

Drug overdose deaths involving cocaine and psychostimulants with abuse potential among racial and ethnic groups - United States, 2004-2019.

BACKGROUND: Drug overdose deaths involving stimulants, including cocaine and psychostimulants with abuse potential (e.g., methamphetamine), have been increasing, partly because of co-involvement with opioids. Stimulant-involved overdose deaths have disproportionately increased among non-Hispanic Black (Black) and non-Hispanic American Indian/Alaskan Native (AI/AN) persons; however, the role of opioids in exacerbating disproportionate stimulant-involved death rates is unclear. METHODS: Analysis of National Vital Statistics System multiple cause-of-death mortality files examined age-adjusted cocaine- and psychostimulant-involved death rates. Analyses of death rates stratified by racial and ethnic group and opioid co-involvement included: 1) Joinpoint regression of 2004-2019 trends, 2) changes in rates from 2018 to 2019, and 3) demographic and geographic characteristics of 2019 deaths. RESULTS: From 2004 to 2019, cocaine and psychostimulant-involved death rates were higher for Black and AI/AN persons, respectively. Among all groups, increases in cocaine-involved overdose rates were largely driven by opioid co-involvement, particularly after 2013. From 2004 to 2019, rates for psychostimulant-involved deaths increased with and without opioid co-involvement. Rates for overdoses co-involving cocaine and synthetic opioids increased from 2018 to 2019 for Hispanic, non-Hispanic White (White), and Black persons. Psychostimulant-involved overdose rates with and without synthetic opioid co-involvement increased among Hispanic, White, and Black persons. In 2019, Black and AI/AN persons continued to experience higher cocaine- and psychostimulant-involved death rates, respectively. CONCLUSIONS: Stimulant-involved deaths continue to increase, and the role of opioids in driving these deaths varies by race and ethnicity. Ensuring equitable access to proven prevention and treatment interventions and incorporating social determinants of health into future research around effective pharmacotherapies may help reduce stimulant-involved overdose deaths.

Recent trends and associated factors of amphetamine-type stimulant overdoses in emergency departments.

BACKGROUND: Emerging data indicate a resurgence of availability and harms of amphetamine-type stimulant (ATS) use. This study examined ATS overdose-involved emergency department (ED) visit trends and visit characteristics associated with ATS overdose. METHODS: Data from the Healthcare Cost and Utilization Project's (HCUP) 2010-2017 Nationwide Emergency Department Sample identified ATS overdose-involved visits. Predicted trend lines from 2010 to 2015 were fit using weighted logistic regression forany or only ATS-involved overdose using ICD-9-CM discharge diagnosis codes; percentage change from 2016 to 2017 used ICD-10-CM. Multivariable logistic regression examined characteristics in 2017 associated with only ATS-involved overdoses compared to drug overdoses not involving ATS. RESULTS: Every year from 2010 to 2015 the odds of any ATS overdose-involved ED visits increased 11 % (odds ratio [OR]: 1.11, 95 % CI: 1.09, 1.14) and 7 % for only ATS overdose-involved visits (OR: 1.07, 95 % CI: 1.04, 1.10). From 2016 to 2017, any and only ATS overdose-involved visit rates increased 19.1 % and 20.5 %, respectively (P < .05). In 2017, ATS overdose-involved visits (N = 42,428) accounted for 4.4 % of all drug overdose visits (N = 956,266). In adjusted regression models, characteristics more prevalent among patients with only ATS overdose included Western region; micropolitan and noncore urbanization levels; unintentional, undetermined, and assault intents; and cardiovascular effects. CONCLUSIONS: Our findings, coupled with the rising availability of ATS and related harms, underscore the expansion of current substance use and overdose prevention and response efforts to address stimulant use, particularly among groups at risk. Research to identify additional individual and community-level risk factors for increasing ATS overdose is warranted.

Nonfatal Drug and Polydrug Overdoses Treated in Emergency Departments - 29 States, 2018-2019.

The U.S. drug overdose epidemic continues to cause substantial morbidity and mortality. In 2017, 967,615 nonfatal drug overdoses were treated in emergency departments (EDs), a 4.3% increase from 2016 in all overdoses and a 3.1% increase in opioid-involved overdoses (1). During 2017 and 2018, syndromic surveillance revealed that 37.2% of overdoses treated in EDs in 18 states involved multiple drugs (2). To describe changes in rates and proportions of suspected nonfatal drug and polydrug overdoses treated in EDs, CDC analyzed syndromic surveillance data from 2018 to 2019 in 29 states. Rates of overdoses involving opioids, cocaine, and amphetamines increased 9.7%, 11.0%, and 18.3%, respectively, and the rate of benzodiazepine-involved overdoses decreased 3.0%. Overdoses co-involving opioids and amphetamines increased from 2018 to 2019, overall, in both sexes, and in most age groups. In 2019, 23.6%, 17.1%, and 18.7% of overdoses involving cocaine, amphetamine, and benzodiazepines, respectively, also involved opioids. Expanding overdose prevention, treatment, and response efforts is needed to reduce the number of drug and polydrug overdoses. This includes linkage into treatment, harm reduction services, and community-based programs for persons who use drugs; expanding overdose prevention efforts, including increased naloxone provision, to persons who use stimulants; addressing the illicit drug supply; and identifying specific risk factors for populations using these drugs. Continued surveillance with expanded coverage of additional jurisdictions of the evolving drug overdose epidemic is important to the success of these efforts.

Variation in Adult Outpatient Opioid Prescription Dispensing by Age and Sex - United States, 2008-2018.

In 2017, prescription opioids were involved in 36% of opioid-involved overdose deaths in the United States (1). Prescription opioids can be obtained by prescription or through diversion (the channeling of regulated drugs from legal to illegal sources) (2). Among new heroin users, 66%-83% reported that their opioid use began with the misuse of a prescription opioid (3). "Misuse" is generally defined as drugs taken for a purpose other than that directed by the prescribing physician, in greater amounts, more often, or for a longer duration than prescribed (2). Exposure to prescription opioids can be lessened by ensuring recommended prescribing, thereby potentially reducing the risk for misuse, opioid use disorder, and overdose (4). Sex and age groups with high exposure to prescription opioids are not well defined. Using a retail pharmaceutical database from IQVIA,* nationwide trends in opioid prescription fill rates for adult outpatients by age and sex were examined during 2008-2018. Opioid prescription fill rates were disproportionately higher among men and women aged ≥65 years and women of all ages. For reasons not well understood, these disparities persisted over 11 years even as the opioid fill rate declined for each age group and sex. Interventions to improve prescribing practices by following evidence-based guidelines that include weighing the benefits and risks for using prescription opioids for each patient and adopting a multimodal approach to pain management could improve patient safety while ameliorating pain. These efforts might need to consider the unique needs of women and older adults, who have the highest opioid prescription fill rates.

Drug and Opioid-Involved Overdose Deaths - United States, 2017-2018.

Of the 70,237 drug overdose deaths in the United States in 2017, approximately two thirds (47,600) involved an opioid (1). In recent years, increases in opioid-involved overdose deaths have been driven primarily by deaths involving synthetic opioids other than methadone (hereafter referred to as synthetic opioids) (1). CDC analyzed changes in age-adjusted death rates from 2017 to 2018 involving all opioids and opioid subcategories* by demographic characteristics, county urbanization levels, U.S. Census region, and state. During 2018, a total of 67,367 drug overdose deaths occurred in the United States, a 4.1% decline from 2017; 46,802 (69.5%) involved an opioid (2). From 2017 to 2018, deaths involving all opioids, prescription opioids, and heroin decreased 2%, 13.5%, and 4.1%, respectively. However, deaths involving synthetic opioids increased 10%, likely driven by illicitly manufactured fentanyl (IMF), including fentanyl analogs (1,3). Efforts related to all opioids, particularly deaths involving synthetic opioids, should be strengthened to sustain and accelerate declines in opioid-involved deaths. Comprehensive surveillance and prevention measures are critical to reducing opioid-involved deaths, including continued surveillance of evolving drug use and overdose, polysubstance use, and the changing illicit drug market; naloxone distribution and outreach to groups at risk for IMF exposure; linkage to evidence-based treatment for persons with substance use disorders; and continued partnerships with public safety.

The rise in non-fatal and fatal overdoses involving stimulants with and without opioids in the United States.

AIMS: To examine trends and recent changes in non-fatal and fatal stimulant overdose rates with and without opioids to improve the descriptive characterization of the US overdose epidemic. DESIGN: Secondary analysis of non-fatal (2006-16) and fatal (2006-17) drug overdose trends, focusing on the most recent years of data available to examine rate changes by demographics (2015-16 for non-fatal and 2016-17 for fatal). SETTING: Non-fatal drug overdoses from the Healthcare Cost and Utilization Project's Nationwide Emergency Department Sample; drug overdose deaths from the National Vital Statistics System. PARTICIPANTS/CASES: International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and Tenth Revision, Clinical Modification/Procedure Coding System (ICD-10-CM/PCS) codes for cocaine, psychostimulants and opioids were used to classify non-fatal drug overdoses. Drug overdose deaths were identified using ICD-10 multiple cause-of-death codes for cocaine, psychostimulants, all opioids, heroin and synthetic opioids. MEASUREMENTS: Percentage of changes in age-adjusted non-fatal and fatal rates of cocaine and psychostimulant-involved drug overdose with and without opioids. FINDINGS: Overall, cocaine-involved non-fatal overdose rates with an opioid increased from 2006 to 2016 [annual percentage change (APC) = 14.7], while rates without an opioid increased from 2006 to 2012 (APC = 11.3) and then remained stable (APC = -7.5). Psychostimulant-involved non-fatal rates with and without an opioid increased from 2006 to 2016 (APC = 49.9 with opioids; 13.9 without opioids). Cocaine-involved death rates with and without opioids increased from 2014 to 2017 (APC = 46.0 with opioids, 23.6 without opioids). Psychostimulant-involved death rates with opioids increased from 2010 to 2015 (APC = 28.6), with a dramatic increase from 2015 to 2017 (APC = 50.5), while rates without opioids increased from 2008 to 2017 (APC = 22.6). In 2016, 27% of non-fatal cocaine- and 14% of psychostimulant-involved overdoses included a reported opioid; 72.7% of cocaine- and 50.3% of psychostimulant-involved deaths involved an opioid in 2017. From 2015 to 2016, cocaine-involved and psychostimulant-involved non-fatal overdose rates with an opioid increased 17.0 and 5.9%, respectively; cocaine-involved and psychostimulant-involved non-fatal overdoses without opioids decreased 13.6 and increased 18.9%, respectively. Death rates involving stimulants increased with and without opioids from 2016 to 2017 (cocaine with and without opioids = 37.7 and 23.3%; psychostimulants with and without opioids = 52.2 and 23.0%). Death rates involving stimulants with synthetic opioids increased dramatically from 2016 to 2017 (1.3-2.3 per 100 000 for cocaine and 0.3-0.8 for psychostimulants). CONCLUSIONS: While increases in cocaine-involved deaths in the United States from 2006 seem to be driven by opioids, particularly synthetic opioids, increases in non-fatal and fatal overdoses involving psychostimulants are occurring with and without opioids.

Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines, Cocaine, and Methamphetamine - 25 States, July-December 2017 to January-June 2018.

From 2013 to 2017, the number of opioid-involved overdose deaths (opioid deaths) in the United States increased 90%, from 25,052 to 47,600.* This increase was primarily driven by substantial increases in deaths involving illicitly manufactured fentanyl (IMF) or fentanyl analogs† mixed with heroin, sold as heroin, or pressed into counterfeit prescription pills (1-3). Methamphetamine-involved and cocaine-involved deaths that co-involved opioids also substantially increased from 2016 to 2017 (4). Provisional 2018§ estimates of the number of opioid deaths suggest a small decrease from 2017. Investigating the extent to which decreases occurred broadly or were limited to a subset of opioid types (e.g., prescription opioids versus IMF) and drug combinations (e.g., IMF co-involving cocaine) can assist in targeting of intervention efforts. This report describes opioid deaths during January-June 2018 and changes from July-December 2017 in 25¶ of 32 states and the District of Columbia participating in CDC's State Unintentional Drug Overdose Reporting System (SUDORS).** Opioid deaths were analyzed by involvement (opioid determined by medical examiner or coroner to contribute to overdose death) of prescription or illicit opioids,†† as well as by the presence (detection of the drug in decedent) of co-occurring nonopioid drugs (cocaine, methamphetamine, and benzodiazepines). Three key findings emerged regarding changes in opioid deaths from July-December 2017 to January-June 2018. First, overall opioid deaths decreased 4.6%. Second, decreases occurred in prescription opioid deaths without co-involved illicit opioids and deaths involving non-IMF illicit synthetic opioids (fentanyl analogs and U-series drugs) (5). Third, IMF deaths, especially those with multiple illicit opioids and common nonopioids, increased. Consequently, IMF was involved in approximately two-thirds of opioid deaths during January-June 2018. Notably, during January-June 2018, 62.6% of all opioid deaths co-occurred with at least one common nonopioid drug. To maintain and accelerate reductions in opioid deaths, efforts to prevent IMF-involved deaths and address polysubstance misuse with opioids must be enhanced. Key interventions include broadening outreach to groups at high risk for IMF or fentanyl analog exposure and overdose. Improving linkage to and engagement in risk-reduction services and evidence-based treatment for persons with opioid and other substance use disorders with attention to polysubstance use or misuse is also needed.

Drug Overdose Deaths Involving Cocaine and Psychostimulants with Abuse Potential - United States, 2003-2017.

In 2016, a total of 63,632 persons died from drug overdoses in the United States (1). Drug overdose deaths involving cocaine, psychostimulants with abuse potential (psychostimulants), or both substances combined increased 42.4% from 12,122 in 2015 to 17,258 in 2016.* Psychostimulants with abuse potential include drugs such as methamphetamine, 3,4-methylenedioxy-methamphetamine (MDMA), dextroamphetamine, levoamphetamine, methylphenidate (Ritalin), and caffeine. From 2015 to 2016, cocaine-involved and psychostimulant-involved death rates increased 52.4% and 33.3%, respectively (1). A total of 70,237 persons died from drug overdoses in the United States in 2017; approximately two thirds of these deaths involved an opioid (2). CDC analyzed 2016-2017 changes in age-adjusted death rates involving cocaine and psychostimulants by demographic characteristics, urbanization levels, U.S. Census region, 34 states, and the District of Columbia (DC). CDC also examined trends in age-adjusted cocaine-involved and psychostimulant-involved death rates from 2003 to 2017 overall, as well as with and without co-involvement of opioids. Among all 2017 drug overdose deaths, 13,942 (19.8%) involved cocaine, and 10,333 (14.7%) involved psychostimulants. Death rates increased from 2016 to 2017 for both drug categories across demographic characteristics, urbanization levels, Census regions, and states. In 2017, opioids were involved in 72.7% and 50.4% of cocaine-involved and psychostimulant-involved overdoses, respectively, and the data suggest that increases in cocaine-involved overdose deaths from 2012 to 2017 were driven primarily by synthetic opioids. Conversely, increases in psychostimulant-involved deaths from 2010 to 2017 occurred largely independent of opioids, with increased co-involvement of synthetic opioids in recent years. Provisional data from 2018 indicate that deaths involving cocaine and psychostimulants are continuing to increase.† Increases in stimulant-involved deaths are part of a growing polysubstance landscape. Increased surveillance and evidence-based multisectoral prevention and response strategies are needed to address deaths involving cocaine and psychostimulants and opioids. Enhancing linkage to care, building state and local capacity, and public health/public safety collaborations are critical components of prevention efforts.

Trends and Patterns of Geographic Variation in Opioid Prescribing Practices by State, United States, 2006-2017.

Importance: Risk of opioid use disorder, overdose, and death from prescription opioids increases as dosage, duration, and use of extended-release and long-acting formulations increase. States are well suited to respond to the opioid crisis through legislation, regulations, enforcement, surveillance, and other interventions. Objective: To estimate temporal trends and geographic variations in 6 key opioid prescribing measures in 50 US states and the District of Columbia. Design, Setting, and Participants: Population-based cross-sectional analysis of opioid prescriptions filled nationwide at US retail pharmacies between January 1, 2006, and December 31, 2017. Data were obtained from the IQVIA Xponent database. All US residents who had an opioid prescription filled at a US retail pharmacy were included. Main Outcomes and Measures: Primary outcomes were annual amount of opioids prescribed in morphine milligram equivalents (MME) per person; mean duration per prescription in days; and 4 separate prescribing rates-for prescriptions 3 or fewer days, those 30 days or longer, those with a high daily dosage (≥90 MME), and those with extended-release and long-acting formulations. Results: Between 2006 and 2017, an estimated 233.7 million opioid prescriptions were filled in retail pharmacies in the United States each year. For all states combined, 4 measures decreased: (1) mean (SD) amount of opioids prescribed (mean [SD] decrease, 12.8% [12.6%]) from 628.4 (178.0) to 543.4 (158.6) MME per person, a statistically significant decrease in 23 states; (2) high daily dosage (mean [SD] decrease, 53.1% [13.6%]) from 12.3 (3.4) to 5.6 (1.7) per 100 persons, a statistically significant decrease in 49 states; (3) short-term (≤3 days) duration (mean [SD] decrease, 43.1% [9.4%]) from 18.0 (5.4) to 10.0 (2.5) per 100 persons, a statistically significant decrease in 48 states; and (4) extended-release and long-acting formulations (mean [SD] decrease, 14.7% [13.7%]) from 7.2 (1.9) to 6.0 (1.7) per 100 persons, a statistically significant decrease in 27 states. Two measures increased, each associated with the duration of prescription dispensed: (1) mean (SD) prescription duration (mean [SD] increase, 37.6% [6.9%]) from 13.0 (1.2) to 17.9 (1.4) days, a statistically significant increase in every state; and (2) prescriptions for a term of 30 days or longer (mean [SD] increase, 37.7% [28.9%]) from 18.3 (7.7) to 24.9 (10.7) per 100 persons, a statistically significant increase in 39 states. Two- to 3-fold geographic differences were observed across states, measured by comparing the ratio of each state's 90th to 10th percentile for each measure. Conclusions and Relevance: In this study, across 12 years, the mean duration and prescribing rate for long-term prescriptions of opioids increased, whereas the amount of opioids prescribed per person and prescribing rate for high-dosage prescriptions, short-term prescriptions, and extended-release and long-acting formulations decreased. Some decreases were significant, but results were still high. Two- to 3-fold state variation in 5 measures occurred in most states. This information may help when state-specific intervention programs are being designed.