A new study published in the Journal of Urban Health could have a significant impact on the way heroin overdose cases are counted and may dramatically increase the number of reported heroin-related deaths across the country.
Researchers at the School of Public and Environmental Affairs at Indiana University-Purdue University Indianapolis and the IU Richard M. Fairbanks School of Public Health at IUPUI analyzed accidental opioid overdoses in Marion County, Indiana, from 2010 through 2015 and discovered that deaths where heroin was present may be significantly undercounted.
During the six-year study period, the IUPUI team examined the death certificates and toxicology reports for 1,199 accidental drug-overdose fatalities in Marion County and classified 455 as heroin-related. During the same time period, the Marion County Public Health Department recorded just 141 deaths caused by heroin.
“What happens a lot of times when people overdose is that they have multiple substances in their system,” said Brad Ray, an assistant professor at SPEA who studies substance abuse. “Because of the use of poly-drug codes to classify deaths when multiple drugs are present, we tend to undercount the prevalence of heroin in deaths because we usually count whether the death was a result of heroin rather than whether heroin was present.”
The team of researchers — Ray, Kenna Quinet and Tim Dickinson from SPEA and Dennis Watson from the School of Public Health — recorded the presence of opioids in 918 cases among the nearly 1,200 that were examined for their report, “Examining Fatal Opioid Overdoses in Marion County, Indiana.” While guidelines from laboratory toxicologists suggest that 6-monoacetylmorphine is the definitive text for illicit heroin, the IUPUI researchers coded cases that had both morphine and codeine — but not 6-monoacetylmorphine — as heroin cases.
According to Ray, heroin undergoes a rapid metabolic transformation into those natural opioids, so heroin-related toxicology reports sometimes show signs of morphine and codeine but not 6-monoacetylmorphine.
“Anytime you would see those two substances together, the research suggests that it has to be heroin,” Ray said. “Being able to work with the Marion County Coroner’s Office and comb through the toxicology reports allowed us to see how often heroin was present in drug-overdose deaths and not just the primary cause of death.”
The number of heroin-related deaths increased more than 400 percent over the six-year time frame, from 22 in 2010 to 111 in 2015. The overdose rate for fentanyl also increased dramatically during the study period, from 15 to 63 (320 percent). Total opioid-related overdoses doubled, from 129 to 260. While deaths from heroin and fentanyl saw sizable increases, overdoses from prescription opiates declined or remained relatively flat.
The researchers were also able to gather Marion County data on prescription-drug patterns from Indiana Scheduled Prescription Electronic Collection and Tracking. They discovered that following large decreases in prescriptions for opioids in 2013 and 2014, there were marked increases in heroin- and fentanyl-related deaths in 2014 and 2015.
Hydrocodone, which had the highest number of opioid overdose deaths — 31 — in 2010, was the most prescribed opioid during the study period, with nearly 9.6 million prescriptions written. But after reaching a high of 1.8 million prescriptions in 2012, hydrocodone prescriptions fell by 30 percent during the last three years of the research period. While hydrocodone accounted for 38 percent of all opioid drug overdoses in 2010, that figure fell to just 17 percent, or 35 deaths, in 2015.
“One of the big hypotheses right now is that people have moved from prescription medication to heroin, and our research would suggest that it’s true,” Ray said. “People start out on pills and move to heroin because it’s cheaper, and at some point they’re usually getting those pills cut off to them. As a community, users have shifted from pills to heroin, and that’s partially what’s driving up our death rate.”
Ray notes that one of the issues with tracking accidental overdose cases in Indiana is a lack of detailed information on the specific opioid substances related to the fatality. But a bill currently moving through the Indiana state legislature could help improve that reporting.
Senate Bill 74 would require coroners who are investigating overdose deaths to perform a “drugs of abuse” panel to detect the presence of Schedule I and Schedule II controlled substances. The results of those deaths would then be forwarded to the Indiana Department of Health.
The bill, which was sponsored by state Sen. Jim Merritt, R-Indianapolis, passed a local government committee in late January and was sent to the Senate appropriations committee, where it currently awaits a hearing.
“This is an incredibly important issue, because we don’t know how many people are actually dying with heroin in their system,” Ray said. “And fentanyl is the drug that has everyone nervous right now. I would bet when we get the 2016 numbers, we’ll be looking at an equal number of deaths between fentanyl and heroin.”