The Opioid Epidemic Might Be Much Worse Than We Thought

Read: The true cause of the opioid epidemic

So the researchers set out to try to determine the real causes behind those unspecified drug overdoses. In the process, they uncovered something unsettling about the way deaths are tracked in the U.S.: The way a given county investigates deaths matters, and it could be dramatically shifting our nationwide estimates of the number of people who die of everything from opioids to childbirth to coronavirus.

Hill worked with Boslett and a Ph.D. candidate, Alina Denham, to come up with a model to estimate how many of those unspecified drug overdoses were caused by opioids. To do it, they set aside some of the death records in which the type of drug was known and created a model that would predict that drug, given other things that were known about that person: the county they lived in, their sex, where they died, other health conditions that contributed to the person’s death, and so on. For opioid deaths, that meant factoring in whether the person had other characteristics typically associated with opioid overdose, like being addicted to opioids or having chronic pain. By applying the model to the “unspecified” overdose deaths, they were able to predict that 72 percent were actually from opioids.

In fact, they estimate in a new study in the journal Addiction, there were over 99,000 more deaths from opioids between 1999 and 2016 than had been previously documented, raising the national death toll by about 28 percent, to 453,300. What’s more, the discrepancies varied widely by state. In Alabama, Mississippi, Pennsylvania, Louisiana, and Indiana, Hill and her team estimated that the number of deaths from opioid overdoses was actually double the previous estimates.

“This paper is a very strong one,” said Atheendar Venkataramani, a health-policy professor at the University of Pennsylvania, who was not involved in the study. It suggests that “if you just follow the vital statistics alone, we’re probably underestimating the true number of opioid deaths,” he said.

Hill and her team suspect that’s because of differences in how counties across the U.S. investigate deaths. In essence, whether a given county uses a coroner or a medical examiner to investigate deaths matters. Medical examiners are doctors specially trained in pathology and forensics, but coroners can be general practitioners or even lay people with no medical training. For coroners, “in many places, like the state of Pennsylvania, the only requirements are to be a legal adult with no felony convictions who has lived in the county for one year and to complete a basic training course,” Jordan Kisner wrote this week in The New York Times Magazine. Meanwhile, as Kisner pointed out, there’s a dire shortage of medical examiners in the United States.

Because of this lower standard of training, Denham explained, “you would think [coroners] would not be able to identify opioid involvement in a death as well as a medical doctor trained in it would.” That inference seems to be held up by data: The states that had a lot of unclassified drug-overdose deaths, Hill and her colleagues found, tended to use coroners in their death investigations.