In an article in the April 2018 issue of the American Journal of Public Health, four researchers at the Centers for Disease Control and Prevention’s Division of Unintentional Injury Prevention report that the CDC’s methods for tracking opioid overdose deaths have over-estimated the number of those deaths due to prescription opioids, as opposed to heroin, illicitly manufactured fentanyl, and other illicit variants of fentanyl. They called the prescription opioid overdose rate “significantly inflated.”

Fentanyl is a synthetic opioid categorized as a prescription opioid. But, in the outpatient setting, it is predominantly prescribed as a time-release transdermal patch, not suitable for nonmedical users. Occasionally, it is prescribed as a lozenge, a nasal spray, or a small film that can be placed within the corner of one’s mouth, usually to cancer patients in extreme pain. These forms of the drug don’t lend themselves to being converted into a form suitable for nonmedical users wishing to snort or inject the drug. The injectable form of fentanyl is almost exclusively used in the hospital setting, both as an anesthetic agent and to control severe pain in patients who are critically ill or in the postoperative recovery room. Over the past several years, the underground market has been flooded by illicitly manufactured fentanyl and its variants, often moved into the country in a powdered form through the mail.

The authors of the AJPH article state, “Traditionally, the Centers for Disease Control and Prevention (CDC) and others have included synthetic opioid deaths in estimates of ‘prescription’ opioid deaths. However, with IMF (illicitly manufactured fentanyl) likely being involved more recently, estimating prescription opioid–involved deaths with the inclusion of synthetic opioid–involved deaths could significantly inflate estimates.” They suggest that under a new “conservative” definition—excluding deaths involving synthetic opioids like fentanyl—the 32,445 prescription opioid-involved deaths that the CDC estimated occurred in 2016 would be revised down to 17,087.

The authors point out that the exact drugs involved in overdose deaths are not identified in 20 percent of death certificates, and the number of deaths due to diverted (stolen, smuggled, or sold by dealers) prescription opioids is unknown. They also note that multiple drugs are involved in over half of their reported cases of prescription opioid overdoses—although other centers report multiple drugs involved in over 90 percent of overdoses. Because of this, they say, even that reduced estimate is likely inaccurate.

In December 2017, the CDC reported that overdose deaths due to fentanyl have been increasing at a rate of 88 percent per year since 2013, and now make up the largest component of opioids responsible for overdose deaths.

The authors go on to state, “Obtaining an accurate count of the true burden and differentiating between prescription and illicit opioid-involved deaths are essential to implement and evaluate public health and public safety efforts…If deaths involving synthetic opioids—likely IMF—are categorized as prescription opioid overdose deaths, then the ability to evaluate the effect of interventions targeting high-risk prescribing practices on prescription opioid–involved deaths is hindered. Decreases in prescription opioid–involved deaths could be masked by increases in IMF deaths, resulting in inaccurate conclusions.”

This last statement is important. Policymakers seem intent on seeing doctors treating patients in pain as the source of the opioid overdose crisis. And their focus has been on getting doctors to curtail prescribing opioids, while ordering a reduction in the manufacture of opioids (25 percent in 2017 and 20 percent this year) by pharmaceutical companies. This has made a lot of patients, in and out of the hospital, suffer from under-treatment of pain. Yet, the government’s own numbers have shown for years that the overdose crisis is primarily the result of nonmedical users seeking drugs in the black market created by drug prohibition. This article from the CDC researchers provides yet another reason why policymakers should rethink their approach.