Overdoses in the ER, 2018–2019: Opioids, Stimulants — and More and More Both at Once

The U.S. drug overdose epidemic keeps causing illness and death on a large scale. In 2017, emergency departments (EDs) treated 967,615 nonfatal overdoses — up 4.3% from 2016 overall and 3.1% for opioid-involved overdoses. In 2017–2018, 37.2% of ED-treated overdoses in 18 states involved more than one drug.

To see what changed next, CDC analysed syndromic surveillance data from EDs in 29 states for 2018 and 2019, looking at suspected nonfatal overdoses — unintentional or of undetermined intent — involving four drug types.

One year's change

Change in the rate of suspected nonfatal overdose ED visits, 2018 to 2019 (relative change; absolute change per 100,000 ED visits):

By age: opioid overdoses rose in every age group; amphetamine overdoses in every age group except 15–24; cocaine overdoses only at 35–44 and 55 and older. Benzodiazepine overdoses fell among people aged 15–24 (−7.3%; −1.7). Opioid-plus-amphetamine overdoses rose in all age groups except 45–54.

By region:

Urban and rural: opioid overdoses rose in both urban (+13.6%; +16.9) and rural counties (+10.1%; +6.1), and so did amphetamine overdoses (urban +21.7%; +1.3, rural +20.8%; +1.9). Opioid-plus-amphetamine overdoses rose in urban counties (+54.1%; +0.5).

Most of the change in multi-drug overdoses came from opioids combined with amphetamines.

Opioids run through it all

In 2019, opioids were involved in 40.2% of all suspected overdoses treated in EDs — and in many overdoses mainly attributed to other drugs:

By age, opioids were involved in 28.7% of overdoses at 15–24, 56.9% at 25–34, 49.9% at 35–54 and 34.6% at 55 and older.

Opioids alone and in combination (A), and the share of stimulant and benzodiazepine overdoses also involving opioids (B), by age, 29 states, 2019. CDC

Reading the trends

• Benzodiazepines fell, but they still appeared in 12.2% of ED-treated nonfatal overdoses in 2017, and they are among the drug classes most often found in overdose deaths — likely because people use them with opioids. Overdoses involving opioids and benzodiazepines together held steady from 2018 to 2019.
• Deaths involving synthetic opioids, mainly illicitly made fentanyl, have risen since 2013. Cocaine and methamphetamine have become more available, and in 2019 methamphetamine was the drug most often reported in the Drug Enforcement Administration's drug submissions.
• The rise in opioid-amphetamine overdoses fits other research showing more people starting methamphetamine, more use of stimulants and opioids together, more stimulant overdoses in EDs and more deaths involving both.

What the authors recommend

• Act sooner. Multi-drug overdoses are climbing; the aim is to intervene before more of them happen, or turn fatal.
• Use the ED visit. Link people to treatment, harm reduction services and community programs.
• Reach people who use stimulants: provide naloxone and overdose education to them too.
• Keep prescribing safe, work with public safety, tackle the illicit drug supply, and understand the social and structural factors behind overdose and the risk factors for each group.
• Widen surveillance. Syndromic surveillance spots overdose spikes and clusters so resources can be sent; covering every U.S. ED visit would show better which populations and places to prioritize.

Limits

• Overdoses were identified by discharge diagnosis codes, missing in 20.3% of visits in these states; visits with valid codes rose 5.3% from 2018 to 2019, which could affect the trends. Hospitals may also use the codes inconsistently.
• Full toxicology testing is rare in ED overdose visits, so multi-drug overdoses may be undercounted.
• Hospital participation changed between years, coverage varies within and between states, and results apply only to participating states.
• Counts are of visits, not people: someone treated twice counts twice. Because the data are meant to show change, not how many people overdosed, the report gives changes rather than counts or rates.
• Race and ethnicity could not be analysed: they were missing from about a third and a half of visits, respectively.

Sources

Based on Liu S, Scholl L, Hoots B, Seth P, "Nonfatal Drug and Polydrug Overdoses Treated in Emergency Departments — 29 States, 2018–2019," MMWR volume 69, number 34, Centers for Disease Control and Prevention; a work of the United States government in the public domain.