Assessment of Excess Mortality Associated With Drug Overdose in Ohio From 2009 to 2018

Despite sustained efforts to reduce drug overdose mortality, drug overdoses continue to be an issue of significant concern in the US.¹ The state of Ohio has the second highest incidence of fatal drug overdose; therefore, Ohio remains an important bellwether of this evolving national issue.² A 2019 study³ reported that more than 500 000 years of life were lost to opioid overdose in Ohio from 2010 to 2016 and that opioid overdose had a measurable effect on life span in the state. However, more work is needed to contextualize these opioid deaths within the broader context of drug misuse and overdose and in relation to other leading causes of mortality. This study builds on our 2019 report³ of overdose mortality burden in Ohio to provide such context.⁴

This cross-sectional study included data from death records obtained from the Ohio Department of Health. The institutional review board of Ohio University determined this study to be nonregulated, and a waiver of consent was granted because data were deidentified administrative records. This study is reported following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

A serial cross-sectional analysis was performed for all unintentional fatal drug overdoses between January 1, 2009, and December 31, 2018. The burden of fatal drug overdose was calculated in years of life lost (YLL), computed by subtracting the age at death from the standard life expectancy for each decedent. Deaths were stratified by age (0-14, 15-19, 20-29, 30-39, 40-49, 50-59, or ≥60 years) and sex. Life expectancy by age and sex was determined from the Social Security Administration Period Life Table.⁵ This procedure was repeated for all causes of death for comparison with drug overdose. Finally, change in mean life span associated with overdose was calculated as

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Analyses were performed using SPSS Statistics version 24 (IBM Corp). Data were analyzed on September 27, 2019.

There were 26 350 unintentional drug overdose deaths in Ohio from January 1, 2009, to December 31, 2018, and opioids were involved in 20 793 deaths (78.9%). Among 1 026 821 YLL, the groups who experienced highest YLL were white individuals (916 144 YLL [89.2%]), men (663 722 YLL [64.6%]), and individuals aged 30 to 39 years (328 007 YLL [31.9%]) or 20 to 29 years (259 144 YLL [25.2%]). Drug overdose was associated with 1 026 821 YLL and was the third leading cause of excess mortality after malignant neoplasms (3 944 244 YLL) and heart disease (3 235 989 YLL). The Figure illustrates drug overdose YLL among leading causes of excess mortality.

All-cause mortality increased 14.2% during the period, with total annual YLL increasing from 1 607 512 YLL in 2009 to 1 836 220 YLL in 2018. A total of 38.2% of this increase was due to drug overdose. The next leading clinical entity, heart disease, accounted for just 12.7% of the increase.

The peak year for overdose deaths was 2017, during which Ohio experienced 187 006 overdose-related YLL, accounting 9.9% of all-cause excess mortality in Ohio and lowering the mean life span by 1.27 years. The Table presents mortality trends during the study.

During the course of a decade, Ohio lost more than 1 million years of human life to drug overdose. Drug overdose contributed more to an observed increase in all-cause mortality than any other cause and was associated with reduced mean life span in 2017. Drug overdose was the third leading cause of excess mortality in Ohio, a fact obfuscated by previous reports that included these deaths in the category of unintentional injury fatalities and reported incidence alone without accompanying YLL.⁶ Our analysis is limited by the use of death certificate data with possibly incomplete cause-of-death reporting.

We recommend that YLL be monitored in states experiencing increased drug overdose burden and that drug overdose YLL be compared with other clinical entities to better contextualize the current era of opioid misuse and overdose. Additionally, drug overdoses should be reported separately from other unintentional injuries in epidemiological research, as reporting them together obscures drug overdose as a leading cause of preventable mortality.

Accepted for Publication: February 11, 2020.

Published: April 7, 2020. doi:10.1001/jamanetworkopen.2020.2183

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Hall OT et al. JAMA Network Open.

Corresponding Author: O. Trent Hall, DO, Department of Psychiatry and Behavioral Health, Ohio State University Wexner Medical Center, 181 Taylor Ave, Talbot Hall, Columbus, OH 43203 (orman.hall@osumc.edu).

Author Contributions: Mr O. E. Hall had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: O. T. Hall, O. E. Hall.

Acquisition, analysis, or interpretation of data: O. E. Hall, Kolodny, Teater, McGrath.

Drafting of the manuscript: O. T. Hall, Kolodny.

Critical revision of the manuscript for important intellectual content: O. T. Hall, O. E. Hall, Teater, McGrath.

Statistical analysis: O. E. Hall.

Obtained funding: O. T. Hall.

Administrative, technical, or material support: O. T. Hall, O. E. Hall, Kolodny.

Supervision: Teater.

Conflict of Interest Disclosures: Dr Kolodny reported receiving grants from the National Institute on Drug Abuse, Partnership for a Drug-Free New Jersey, the Robert Wood Johnson Foundation, and the US Food and Drug Administration outside the submitted work and serving as executive director of Physicians for Responsible Opioid Prescribing and as an expert witness in litigation involving opioid analgesics. No other disclosures were reported.

Funding/Support: This study was supported by the Ohio Alliance for Innovation in Population Health. Dr O. T. Hall received funding from the Recognizing and Eliminating Disparities in Addiction Through Culturally Informed Healthcare (REACH) program, which is made possible by funding to the American Academy of Addiction Psychiatry from the Substance Abuse and Mental Health Services Administration (grant 1H79TI08135801).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The views expressed in this publication do not necessarily reflect the official policies of the Department of Health and Human Services, nor does mention of trade names, commercial practices, or organizations imply endorsement by the US government.