Heroin Overdose Deaths Research Articles

Differences in heroin overdose deaths in Australia by age, 2020-2022: Disease and estimated survival times

BackgroundThe age of people who use illicit opioids has increased, with a clinical picture of accelerated ageing. The study aimed to determine, stratified by age: 1. The circumstances and characteristics of heroin-related toxicity deaths in Australia, 2020–2022; 2. The toxicological profile and autopsy findings; 3. The proportion of cases in which blood 6-acetyl morphine (6AM) was detected, as a measure of survival time. MethodsRetrospective study of 610 cases of fatal heroin-related drug toxicity in Australia, 2020–2022. Cases were stratified as: <30 years, 30–39 years, 40–49 years, ≥50 years. ResultsCompared to the youngest group, those aged ≥50 years were more likely to have a history of chronic pain (12.4 v 3.3 %), to have their death attributed to combined drug toxicity/disease (20.1 v 3.3 %), and to have evidence of a sudden collapse (21.3 v 11.1 %). There were no differences in free morphine concentrations or glucuronide concentrations. Compared to the youngest group, however, the two older groups were significantly more likely to have 6AM present in blood, a proxy measure of a shorter survival time (52.0, 55.2 v 34.5 %). Compared to the youngest group, cases aged ≥50 years were more likely to be diagnosed with cardiomegaly (44.0 v 16.7 %), coronary artery disease (46.0 v 15.0 %), emphysema (35.0 v 5.1 %), hepatic steatosis (15.4 v 3.4 %), hepatic fibrosis (17.6 v 3.4 %), and cirrhosis (19.8 v 0.0 %). ConclusionsOlder cases of heroin overdose had more extensive heart, lung, and liver disease, and appeared more likely to have shorter survival times.

The impact of hydrocodone rescheduling on utilization, abuse, misuse, and overdose deaths.

To evaluate the impact of increased federal restrictions on hydrocodone combination product (HCP) utilization, misuse, abuse, and overdose death. We assessed utilization, misuse, abuse, and overdose death trends involving hydrocodone versus select opioid analgesics (OAs) and heroin using descriptive and interrupted time-series (ITS) analyses during the nine quarters before and after the October 2014 rescheduling of HCPs from a less restrictive (CIII) to more restrictive (CII) category. Hydrocodone dispensing declined >30% over the study period, and declines accelerated after rescheduling. ITS analyses showed that immediately postrescheduling, quarterly hydrocodone dispensing decreased by 177M dosage units while codeine, oxycodone, and morphine dispensing increased by 49M, 62M, and 4M dosage units, respectively. Postrescheduling, hydrocodone-involved misuse/abuse poison center (PC) case rates had a statistically significant immediate drop but a deceleration of preperiod declines. There were small level increases in codeine-involved PC misuse/abuse and overdose death rates immediately after HCP's rescheduling, but these were smaller than level decreases in rates for hydrocodone. Heroin-involved PC case rates and overdose death rates increased across the study period, with exponential increases in PC case rates beginning 2015. HCP rescheduling was associated with accelerated declines in hydrocodone dispensing, only partially offset by smaller increases in codeine, oxycodone, and morphine dispensing. The net impact on hydrocodone and other OA-involved misuse/abuse and fatal overdose was unclear. We did not detect an immediate impact on heroin abuse or overdose death rates; however, the dynamic nature of the crisis and data limitations present challenges to causal inference.

Understanding the differential effect of local socio-economic conditions on the relation between prescription opioid supply and drug overdose deaths in US counties.

Both local socio-economic conditions and prescription opioid supply are associated with drug overdose deaths, which exhibit substantial geographical heterogeneity across the United States. We measured whether the associations of prescription opioid supply with drug overdose deaths vary by local socio-economic conditions. Ecological county-level study, including 3109 US counties between 2006 and 2019 (n = 43 526 county-years) using annual mortality data. United States. A total of 711 447 drug overdose deaths. We modeled overdose counts using Bayesian hierarchical Poisson models, estimating associations between four types of drug overdose deaths (deaths involving any drugs, any opioid, prescription opioids only and heroin), prescription opioid supply and five socio-economic indicators: unemployment, poverty rate, income inequality, Rey index (components include mean household income, % high school graduates, % blue-collar workers and unemployment rate), and American human development index (HDI; an indicator of community wellbeing). Drug overdose deaths and all substance-specific overdose deaths were higher in counties with higher income inequality [adjusted odds ratios (aORs) = 1.09-1.13], Rey index (aORs = 1.15-1.21) and prescription opioid supply (aORs = 1.14-1.21), and lower in counties with higher HDI scores (aORs = 0.75-0.92). Poverty rate, income inequality and HDI scores were found to modify the effect of prescription opioid supply on heroin overdose deaths. The plot of the interactions showed that when disadvantage is high, increasing prescription opioid supply does not increase heroin overdose deaths. The less disadvantage there is, indicated by lower poverty rates, higher HDI scores and lower income inequality, the greater the effect of increasing prescription opioid supply relative to population size on heroin overdose deaths in US counties. In the United States, prescription opioid supply is associated with higher drug overdose deaths; associations are stronger in counties with less disadvantage and less income inequality, but only for heroin overdose deaths.

Electronic prescription monitoring and the opioid epidemic

To combat the nationwide opioid epidemic, many states have implemented policies that require prescribers to check a patient's prescription history with Prescription Drug Monitoring Programs (PDMPs) prior to initiating or refilling opioid prescriptions. Using a difference‐in‐differences approach, we show that after states mandated PDMP use, opioid prescriptions decreased by 6.1% as intended. However, PDMP mandates had the unintended effect of driving existing opioid users towards more lethal illicit substitutes such as heroin. We found that reductions in prescription rates were accompanied by unprecedented rises in heroin overdose deaths: there were 6.37 more heroin‐related deaths per million population per year—a 50.1% increase—following PDMP mandates. Although stronger PDMP mandates (e.g., based on comprehensiveness, legal enforcement, integration with other health records, and interstate information sharing) reduced opioid prescriptions, we also find that stronger mandates inadvertently increased heroin overdose deaths. Additional analyses show that the substitution effect was not statistically significant among states with lower preexisting levels of pain reliever dependence, lower heroin availability, and greater access to substance abuse treatment. These findings point to an important policy implication: supply‐side restrictions such as mandated PDMP need to account for possible demand‐side substitution effects.

Increasing trend in accidental pharmaceutical opioid overdose deaths and diverging overdose death correlates following the opioid prescription policy liberalization in Norway 2010-2018.

During the last decade, opioid prescription policies in Norway have been liberalised and pharmaceutical opioid (PO) dispensing has increased. Against this backdrop, we examined the trends in and the correlates of accidental overdose deaths attributable to PO in the period 2010-2018 in comparison with traditional heroin overdose deaths. Accidental overdose deaths attributable to PO or heroin were identified through the Norwegian Cause of Death Registry (n = 1267) and cross-linked with population and patient registries. Overdose death correlates were examined using multivariable logistic regression. The trend in accidental overdose deaths attributable to PO increased significantly from 2010 to 2018. Females, people aged 50 years or older, disability pension recipients and/or those with the highest net wealth had a greater risk of a PO vs. heroin overdose death, while those dying in public spaces, living in urban areas, having recent specialized drug treatment encounters, and/or criminal charge(s) had a lower risk. Among those with primary health care encounters, those with back problems and accidents and injuries had a greater risk of a PO vs. heroin overdose death, while those with a substance use disorder had a lower risk. The increase in accidental overdose deaths attributable to PO coincides with the period of opioid prescription policy liberalization and an increase in PO consumption in Norway. The PO and heroin overdose deaths differed in terms of the associated sociodemographic characteristics, primary and secondary health care encounters, diagnoses, and criminal charges, indicating a need for additional interventions aimed at preventing PO overdose deaths specifically.

Heroin and fentanyl overdose deaths among cases age 50+ in the National Poison Data System, 2015–2020

Context Illicit opioid use and heroin treatment admissions among individuals age 50+ have increased. Little research has, however, examined correlates of illicit opioid overdose deaths in this age group before or during the COVID-19 pandemic or the healthcare services used in these cases. Methods The sample included illicit opioid (heroin, fentanyl, or other synthetic, nonpharmaceutical opioids) poisoning cases age 50+ (N = 5576) in the National Poison Data System (NPDS), 2015–2020. Using descriptive statistics and logistic regression models, we report changes in overdose death rates during the study period and associations of death with healthcare service use, naloxone administration, and clinical and demographic characteristics. Results The 6-year average overdose death rate from illicit opioids among those age 50+ was 2.9%, increasing from 1.4% in 2015 to 4.0% in 2019 and 3.6% in 2020. Logistic regression results showed that exposure year was not a significant factor in the odds of overdose death; however, odds were significantly higher among cases that were not managed at any healthcare facility (HCF) (adjusted odds ratio [AOR] = 4.60, 95% confidence interval [CI] = 3.19–6.63) and lower among those who received naloxone therapy (AOR = 0.64, 95% CI = 0.45–0.92). The odds of death were also higher among cases involving exposure at own or another’s home and co-use of prescription opioids, alcohol, and other illicit drugs. Conclusions Although the NPDS did not show increases in illicit opioid overdose death rates among cases age 50+ in 2020 compared to 2019, overdose deaths were greater among cases that were not managed at HCF and did not receive naloxone therapy. Many appear to have died before they received any intervention to prevent death. Improved access to healthcare services and social support and access to naloxone therapy for older adults with opioid use problems are needed.

Spatiotemporal Analysis of the Association Between Pain Management Clinic Laws and Opioid Prescribing and Overdose Deaths.

Pain management clinic (PMC) laws were enacted by 12 states to promote appropriate opioid prescribing, but their impact is inadequately understood. We analyzed county-level opioid overdose deaths (National Vital Statistics System) and patients filling long-duration (≥30 day) or high-dose (≥90 morphine milligram equivalents per day) opioid prescriptions (IQVIA, Inc.) in the United States in 2010-2018. We fitted Besag-York-Mollié spatiotemporal models to estimate annual relative rates (RRs) of overdose and prevalence ratios (PRs) of high-risk prescribing associated with any PMC law and 3 provisions: payment restrictions, site inspections, and criminal penalties. Laws with criminal penalties were significantly associated with reduced PRs of long-duration and high-dose opioid prescriptions (adjusted PR = 0.82, 95% credible interval (CrI): 0.82, 0.82, and adjusted PR = 0.73, 95% CI: 0.73, 0.74 respectively) and reduced RRs of total and natural/semisynthetic opioid overdoses (adjusted RR = 0.86, 95% CrI: 0.80, 0.92, and adjusted RR = 0.84, and 95% CrI: 0.77, 0.92, respectively). Conversely, PMC laws were associated with increased relative rates of synthetic opioid and heroin overdose deaths, especially criminal penalties (adjusted RR = 1.83, 95% CrI: 1.59, 2.11, and adjusted RR = 2.59, 95% CrI: 2.22, 3.02, respectively). Findings suggest that laws with criminal penalties were associated with intended reductions in high-risk opioid prescribing and some opioid overdoses but raise concerns regarding unintended consequences on heroin/synthetic overdoses.

The Hill event examines increasing mental health, SUD issues amid COVID‐19

For every suicide in this country, there are at least 29 attempts. Heroin addiction and overdose deaths have been on the rise since the pandemic began, which is not a coincidence, given that many people are using drugs as a way of self‐medicating to mask mental health issues. These observations by the co‐chair of the Mental Health Caucus and its Suicide Prevention Task Force were heard during a livestreamed event last week led by The Hill and sponsored by The Hartford.

The fentanyl phase of the opioid epidemic in Cuyahoga County, Ohio, United States.

Since late 2014, fentanyl has become the major driver of opioid mortality in the United States. However, a descriptive analysis of fentanyl victims is limited. We studied the 2016 fentanyl and heroin overdose deaths and compared them to previously studied heroin-associated fatalities from 2012 over a wide range of demographic and investigative variables, including overdose scene findings, toxicology results, and prescription drug history. We observed a significant increase in fentanyl-related deaths (n=421, 2016) versus heroin deaths (n=160, 2012) but the baseline demographics between both cohorts remained similar. Victims were predominantly of ages 35-64years (60%-64%), White (83%-85%), and male (73%-76%). 2016 fentanyl decedents were more likely to have naloxone administered upon overdose, and the majority still had a positive prescription history for a controlled substance. Toxicology data showed a decrease in mean morphine and 6-monoacetylmorphine concentrations when cointoxication with fentanyl occurred. Our study emphasizes the medical examiner's role as a public health data source and bridge between different stakeholders combating the opioid epidemic.

Examining the neighborhood-level socioeconomic characteristics associated with fatal overdose by type of drug involved and overdose setting

BackgroundFatal drug overdose in the United States is a public health crisis fueled by increased opioid and polysubstance use. Few studies have compared the neighborhood-level socioeconomic characteristics associated with overdoses of various substance classes and, to our knowledge, no investigation has yet assessed these factors in relation to polysubstance overdoses. Further, no study has determined whether socioeconomic conditions predict other contextually relevant aspects of overdoses such as whether they occur at-home or out-of-home. MethodsOverdose data (2015–2018) were obtained from the Coroner/Medical Examiner’s Office of Jefferson County, Alabama. The toxicology results of decedents with a known overdose locations (N = 768) were assessed for the presence of synthetic opioids, natural and semi-synthetic opioids, heroin, stimulants, benzodiazepines, and alcohol. Socioeconomic characteristics were obtained from the Unites States Census Bureau at the census tract level. ResultsStimulant overdoses occurred in neighborhoods with the highest rates of disadvantage relative to other substance and polysubstance overdose types. The majority of included overdoses occurred at-home (63.7%) and an index of socioeconomic disadvantage predicted overdose rates for both at-home and out-of-home overdoses. Heroin overdose deaths were more likely to occur at-home while polysubstance stimulant-heroin overdoses were more common out-of-home. ConclusionsAn index of socioeconomic disadvantage was generally predictive of overdose, regardless of the setting in which the overdose occurred (in-home vs. out-of-home). The associations between neighborhood-level socioeconomic characteristics and fatal overdose can be tailored by substance type to create targeted interventions. Overdose setting may be an important consideration for future policy efforts, as overdoses were nearly twice as likely to occur at-home.

Is Europe Facing an Emerging Opioid Crisis Comparable to the U.S.?

In the U.S., an opioid overdose crisis has emerged, attributable to over-prescription of opioid analgesics, driven by aggressive marketing by pharmaceutical companies, followed by surging heroin overdose deaths, and more recently, by the high mortality rates predominately because of illicitly manufactured fentanyl and analogs of fentanyl. In Europe, the use of prescription opioids for pain management has also increased in the last 2 decades, although it is debatable as to whether this could lead to a similar opioid overdose crisis. To address this issue, recent trends in opioid prescription rates, prevalence rates of fatal and nonfatal incidents, and addiction care treatment were used as proxies of opioid-related harm. The current overview, comparing opioid use and its negative consequences in Germany, France, the U.K., and the Netherlands, using the same indicators as in the U.S., demonstrates that there is no evidence of a current or emerging opioid crisis in these European countries. Scotland, however, is an alarming exception, with high rates of opioid-related harms. Considering that the use of prescription opioids has been declining rather than increasing in Europe, an opioid crisis is not anticipated there yet. Authorities should, however, remain vigilant.

Characteristics and circumstances of heroin and pharmaceutical opioid overdose deaths: Comparison across opioids

BackgroundAlthough much is known about the correlates of heroin overdose, less is known about pharmaceutical opioid (PO) overdose. This study aimed to examine correlates of opioid overdose deaths by opioid and compare correlates between opioids. MethodsAnalysis of opioid overdose deaths in Australia between 2000–2015, extracted from the National Coronial Information System (NCIS). The NCIS is an online database of deaths reportable to the coroner, and contains coroner’s findings, autopsy and toxicology reports. Deaths were categorized into mutually exclusive groups: 1) Heroin deaths; and 2) PO deaths (excluding heroin). PO deaths were examined by individual opioid. ResultsThere were 10,795 opioid overdose deaths over the study period. Relative to deaths occurring in major cities, deaths in regional/remote areas had 15.2 (95 % CI: 11.5–20.2) times the risk of being attributed to pharmaceutical fentanyl than heroin. Relative to deaths among people without a recorded history of chronic pain, deaths among people with a recorded history of chronic pain had a 1.9–10.7-fold increased risk of the death being attributed to POs than heroin. Deaths among people with a recorded history of substance use problems where the opioid was injected prior to death had 7.2 and 1.7 times the risk of being attributed to methadone and pharmaceutical fentanyl (respectively) than heroin. ConclusionsFindings suggest the need to: educate PO consumers about the risks of overdose at the time of prescribing; increase coverage and engagement in opioid dependence treatment (particularly in regional/remote areas); and increase uptake of take-home naloxone to reduce opioid overdose mortality.

“They're making it so hard for people to get help:” Motivations for non-prescribed buprenorphine use in a time of treatment expansion

BackgroundBuprenorphine maintenance therapy (BMT) has been widely recognized as one of the most effective treatments for opioid use disorders (OUD). In the midst of the U.S. opioid overdose crisis, local, state, and federal authorities have attempted to increase the availability of BMT, yet few individuals meeting the criteria for OUD utilize BMT. Moreover, recent research suggests that a significant proportion of individuals who use opioids seek out buprenorphine on the illicit market to self-govern and manage withdrawal sickness. MethodsThis paper presents data from a geographic sub-sample within a multi-site study of buprenorphine diversion in Pennsylvania. We endeavor to bolster a slim qualitative literature on the use of non-prescribed buprenorphine through in-depth interviews with 20 individuals who reported buying or receiving buprenorphine outside of medically-sanctioned contexts. Interviews characterized participants’ reasons for both using non-prescribed buprenorphine and eschewing formal treatment, in a state (Pennsylvania) afflicted with high rates of heroin use and overdose deaths. Transcripts were initially coded for broad interview topics, while latent themes relating to buprenorphine diversion and extra-medical use also emerged. ResultsAnalyses revealed complex motivations underlying participants’ extra-medical use of buprenorphine. Where some expressed a desire for treatment autonomy and treatment medications that could not be achieved or obtained within BMT, individuals also indicated a persistent lack of treatment availability and access due to diverse barriers. ConclusionThis study shows how issues related to availability, accessibility, and acceptability many explain low rates of BMT utilization, even within a place and time defined by medication-assisted treatment expansion. Beyond offering broad rhetorical and financial support for MAT, our findings suggest that governmental actors should continue to pursue policies that expand the spatial distribution of BMT. It also underscores the need to look beyond current models of buprenorphine maintenance and to consider modes of buprenorphine delivery beyond long-term maintenance.

Using the CA Opioid Overdose Surveillance Dashboard to track opioid overdose deaths

Using the CA Opioid Overdose Surveillance Dashboard to track opioid overdose deaths

Opioid Seizures by Law Enforcement in Relation to Emergency Room Visits

Opioid Seizures by Law Enforcement in Relation to Emergency Room Visits

Effect of pill mill laws on opioid overdose deaths in Ohio & Tennessee: A mixed-methods case study

Pill mill laws impose strict regulations on pain management clinics to prevent them from issuing opioid prescriptions without medical indication. To date, little is known about the implementation or effects of these laws on opioid overdose deaths. A previously untested concern is that by restricting access to prescription opioids, pill mill laws could increase overdose from heroin and synthetic opioids, like illicitly produced fentanyl. We evaluated the effects of pill mill laws on opioid overdose deaths in Ohio and Tennessee. Of the 11 total U.S. states with pill mill laws, Ohio and Tennessee were the only two where: (1) the pill mill law was the only state law designed to curb opioid prescribing implemented in a two-year period, one-year pre/post law; and (2) high-quality drug-specific overdose death data were available from CDC. We conducted synthetic control analyses examining differences in post-pill mill law trends in overdose deaths in Ohio and Tennessee compared to weighted combinations of comparison states. We also conducted qualitative interviews with 11 leaders responsible for pill mill law implementation and enforcement in Ohio and Tennessee. Pill mill law enactment had no effects on overall, prescription opioid, heroin, or synthetic opioid overdose deaths in Ohio or Tennessee. Interview results suggest that both states engaged in robust enforcement and implementation of the law. A multi-pronged policy approach, including but not limited to pill mill laws, may be required to effectively address opioid overdose deaths.

Assessing Spatial Relationships between Prescription Drugs, Race, and Overdose in New York State from 2013 to 2015

ABSTRACTOver the last decade, New York State has experienced one of the greatest increases in opioid overdose deaths in the United States, particularly from heroin and synthetic opioids. This study investigated spatial patterns in the distribution of county-level rates of overdose deaths in New York State and associations between prescriptions for opioid pain relievers, race, and overdose deaths from 2013–2015. Global and local Moran’s I tests for spatial autocorrelation examined Bayesian smoothed rates of overdose for clusters of counties with high and low rates of overdose mortality. Getis Ord* analyses identified local hotspots of high and low clusters of overdose. Model performance indicators selected the best-fitting spatial regression model to examine associations between prescriptions for opioid pain relievers, race/ethnicity (non-Hispanic White, Black, and Hispanic) after adjusting for spatial dependence in the data. Socio-demographic characteristics of clusters were examined. Findings suggest rates of opioid overdose deaths are clustered in New York. Rates of prescription opioids were associated with rates of overdose from any opioid, prescription pain relievers, and synthetic opioids. Greater populations of African Americans were associated with greater rates of heroin overdose death rates. Findings from this study inform public health opioid overdose prevention interventions and policies.

Challenges with take-home naloxone in reducing heroin mortality: a review of fatal heroin overdose cases in Victoria, Australia

Aim: Take-home naloxone (THN) programs have been implemented in order to reduce the number of heroin-overdose deaths. Because of recent legislative changes in Australia, there is a provision for a greater distribution of naloxone in the community, however, the potential impact of these changes for reduced heroin mortality remains unclear. The aim of this study was to examine the characteristics of the entire cohort of fatal heroin overdose cases and assess whether there was an opportunity for bystander intervention had naloxone been available at the location and time of each of the fatal overdose events to potentially avert the fatal outcome in these cases.Methods: The circumstances related to the fatal overdose event for the cohort of heroin-overdose deaths in the state of Victoria, Australia between 1 January 2012 and 31 December 2013 were investigated. Coronial data were investigated for all cases and data linkage was performed to additionally investigate the Emergency Medical Services information about the circumstances of the fatal heroin overdose event for each of the decedents.Results and Discussion: There were 235 fatal heroin overdose cases identified over the study period. Data revealed that the majority of fatal heroin overdose cases occurred at a private residence (n = 186, 79%) and where the decedent was also alone at the time of the fatal overdose event (n = 192, 83%). There were only 38 cases (17%) where the decedent was with someone else or there was a witness to the overdose event, and in half of these cases the witness was significantly impaired, incapacitated or asleep at the time of the fatal heroin overdose. There were 19 fatal heroin overdose cases (8%) identified where there was the potential for appropriate and timely intervention by a bystander or witness.Conclusion: This study demonstrated that THN introduction alone could have led to a very modest reduction in the number of fatal heroin overdose cases over the study period. A lack of supervision or a witness to provide meaningful and timely intervention was evident in most of the fatal heroin overdose cases.

Opioid Overdose Mortality Among Former North Carolina Inmates: 2000-2015.

To examine differences in rates of opioid overdose death (OOD) between former North Carolina (NC) inmates and NC residents and evaluate factors associated with postrelease OOD. We linked NC inmate release data to NC death records, calculated OOD standardized mortality ratios to compare former inmates with NC residents, and calculated hazard ratios to identify predictors of time to OOD. Of the 229 274 former inmates released during 2000 to 2015, 1329 died from OOD after release. At 2-weeks, 1-year, and complete follow-up after release, the respective OOD risk among former inmates was 40 (95% confidence interval [CI] = 30, 51), 11 (95% CI = 9.5, 12), and 8.3 (95% CI = 7.8, 8.7) times as high as general NC residents; the corresponding heroin overdose death risk among former inmates was 74 (95% CI = 43, 106), 18 (95% CI = 15, 21), and 14 (95% CI = 13, 16) times as high as general NC residents, respectively. Former inmates at greatest OOD risk were those within the first 2 weeks after release, aged 26 to 50 years, male, White, with more than 2 previous prison terms, and who received in-prison mental health and substance abuse treatment. Former inmates are highly vulnerable to opioids and need urgent prevention measures.

Sociodemographic factors, prescription history and opioid overdose deaths: a statewide analysis using linked PDMP and mortality data

BackgroundOpioid overdose deaths have continued to rise in Tennessee (TN) with fentanyl emerging as a major contributor. Current data are needed to identify at-risk populations to guide prevention strategies. We conducted a large statewide observational study among TN adult decedents (2013–2016) to evaluate the association of sociodemographic factors and prescribing patterns with opioid overdose deaths. MethodsAmong drug overdose decedents identified using death certificate data (n = 5483), we used logistic regression to estimate adjusted odds ratios and 95% confidence intervals for characteristics associated with prescription opioid (PO) (excluding fentanyl), fentanyl, and heroin alone overdoses. Among decedents linked to TN’s Prescription Drug Monitoring Database using deterministic algorithms, we obtained prescription history in the year before death (n = 3971), which was evaluated by type of overdose using descriptive statistics. ResultsYounger, non-White decedents had lower odds of PO overdose, while females and benzodiazepines as a contributing cause were associated with increased odds of PO overdose. Younger age, Non-Hispanic Black race/ethnicity, greater than high school education, and cocaine/other stimulants as a contributing cause were associated with increased odds of fentanyl or heroin overdoses. Over 55% of PO, 39.2% of fentanyl, and 20.7% of heroin overdoses had an active opioid prescription at death. For PO, fentanyl, and heroin decedents, respectively, 46.0%, 30.5%, and 26.2% had an active prescription for benzodiazepines at death. ConclusionsPrescription opioid overdose deaths were associated with different sociodemographic profiles and prescribing history compared to fentanyl and heroin overdose deaths in TN. Data can guide prevention strategies to reduce opioid overdose mortality.