Abstract
Mortality data in most countries are reported using the International Classification of Diseases (ICD), managed by the WHO. In this paper, we show how the ICD is ill-suited for classifying drug-involved deaths, many of which involve polysubstance abuse and/or illicitly manufactured fentanyl (IMF).Opioids identified in death certificates are categorized according to six ICD T-codes: opium (T40.0), heroin (T40.1), methadone (T40.3), other synthetic narcotics (T40.4), and other and unspecified narcotics (T40.6). Except for opium, heroin, and methadone, all other opioids except those that are unspecified are aggregated in two T-codes (T40.2 and T40.4), depending upon whether they are natural/semisynthetic or synthetic opioids other than methadone. The result is a system that obscures the actual cause of most drug overdose deaths and, instead, just tallies the number of times each drug is mentioned in an overdose situation.We examined the CDC’s methodology for coding other controlled substances according to the ICD and found that, besides fentanyl, the ICD does not distinguish between other licit and illicitly manufactured controlled substances. Moreover, we discovered that the CDC codes all methadone-related deaths as resulting from the prescribed form of the drug. These and other anomalies in the CDC’s mortality reporting are discussed in this report.We conclude that the CDC was at fault for failing to correct the miscoding of IMF. Finally, we briefly discuss some of the public policy consequences of this error, the misguided focus by public health and safety officials on pharmaceutical opioids, their prescribers and users, and the pressing necessity for the CDC to reassess how it measures and reports drug-involved mortality.
Highlights
BackgroundVital statistics provide an important measure of a nation’s health and welfare
We examined the Centers for Disease Control and Prevention (CDC)’s methodology for coding other controlled substances according to the International Classification of Diseases (ICD) and found that, besides fentanyl, the ICD does not distinguish between other licit and illicitly manufactured controlled substances
Drug-involved overdose deaths pose a unique problem for medical examiners and coroners because of the unavoidable delay in receiving postmortem toxicology results
Summary
Vital statistics provide an important measure of a nation’s health and welfare. In this report, we focus on mortality statistics compiled and reported by the Centers for Disease Control and Prevention (CDC). In drug overdose death cases, significant epidemiologic information is lost when each drug mentioned in the death certificate finds its way into a specific ICD T-code category This enables CDC officials to be able to state a percentage of drug overdose deaths each year in which, for example, T40.2 or T42.4 drugs were involved. The CDC analysts reported that until 2016, the NVSS calculated annual prescription opioid overdose deaths by summing deaths coded T40.2, T40.3, and T40.4 [57] The latter code - T40.4 - was identified as the source of error in the 2016 data [58]. Given what is known about ICD coding and how its use skewed CDC mortality figures for prescription opioid overdose deaths in 2016, the subject of how the CDC codes methadone-involved deaths demand scrutiny. Given the expansion of out-patient treatment of OUD with buprenorphine in the last decade, it is reasonable to assume the increased volume of prescribed buprenorphine depicted reflects the increased prescribing of the drug for OUD treatment [80]
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