Death certificate data are used to track underlying and contributing causes of death, to understand the burden of drug overdose deaths for prevention. The underlying cause of death is the disease or injury that initiated the events leading to death while the contributing causes of death are diseases or injuries that contributed to the fatal outcome. Data are collected by the IDOH Division of Vital Records. A final dataset is provided by the IDOH, Office of Data and Analytics, and Data Analysis Team and analyzed by the Division of Trauma and Injury Prevention to identify overdose deaths among Indiana residents. Deaths are reported back to the county of residence of the Indiana decedent.

Drug overdose death counts involving opioid pain reliever (displayed above) include the following codes:

Underlying Cause of Death Codes (Opioid Pain Reliever):

• X40 to X44 - Accidental poisoning by drugs
• X60 to X64 - Intentional self-poisoning by drugs
• X85 - Assault by drug poisoning
• Y10 to Y14 - Drug poisoning of undetermined intent

Contributing Cause of Death codes (Opioid Pain Relievers):

• T40.2 - Natural and semisynthetic opioids
• T40.3 - Methadone
• T40.4 - Synthetic opioids

Page last updated: October 3, 2023

Healthcare providers report concerns about opioid-related risks of addiction and overdose for their patients, as well as insufficient training in pain management. The 2022 CDC Guideline for Prescribing Opioids for Chronic Pain offers 12 recommendations that may help to improve prescribing practices and ensure all patients receive safer, more effective pain treatment.

Prescribing Recommendations:

1. Nonopioid therapies are at least as effective as opioids for many common types of acute pain.
   1. Clinicians should maximize use of nonpharmacologic and nonopioid pharmacologic therapies as appropriate for the specific condition and patient and only consider opioid therapy for acute pain if benefits are anticipated to outweigh risks to the patient. Before prescribing opioid therapy for acute pain, clinicians should discuss with patients the realistic benefits and known risks of opioid therapy
2. Nonopioid therapies are preferred for subacute and chronic pain.
   1. Clinicians should maximize use of nonpharmacologic and nonopioid pharmacologic therapies as appropriate for the specific condition and patient and only consider initiating opioid therapy if expected benefits for pain and function are anticipated to outweigh risks to the patient. Before starting opioid therapy for subacute or chronic pain, clinicians should discuss with patients the realistic benefits and known risks of opioid therapy, should work with patients to establish treatment goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks
3. When starting opioid therapy for acute, subacute, or chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release and long-acting (ER/LA) opioids
4. When opioids are initiated for opioid-naïve patients with acute, subacute, or chronic pain, clinicians should prescribe the lowest effective dosage.
   1. If opioids are continued for subacute or chronic pain, clinicians should use caution when prescribing opioids at any dosage, should carefully evaluate individual benefits and risks when considering increasing dosage, and should avoid increasing dosage above levels likely to yield diminishing returns in benefits relative to risks to patients
5. For patients already receiving opioid therapy, clinicians should carefully weigh benefits and risks and exercise care when changing opioid dosage.
   1. If benefits outweigh risks of continued opioid therapy, clinicians should work closely with patients to optimize nonopioid therapies while continuing opioid therapy. If benefits do not outweigh risks of continued opioid therapy, clinicians should optimize other therapies and work closely with patients to gradually taper to lower dosages or, if warranted based on the individual circumstances of the patient, appropriately taper and discontinue opioids. Unless there are indications of a life-threatening issue such as warning signs of impending overdose (e.g., confusion, sedation, or slurred speech), opioid therapy should not be discontinued abruptly, and clinicians should not rapidly reduce opioid dosages from higher dosages
6. When opioids are needed for acute pain, clinicians should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids
7. Clinicians should evaluate benefits and risks with patients within 1–4 weeks of starting opioid therapy for subacute or chronic pain or of dosage escalation.
   1. Clinicians should regularly reevaluate benefits and risks of continued opioid therapy with patients
8. Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk for opioid-related harms and discuss risk with patients.
   1. Clinicians should work with patients to incorporate into the management plan strategies to mitigate risk, including offering naloxone
9. When prescribing initial opioid therapy for acute, subacute, or chronic pain, and periodically during opioid therapy for chronic pain, clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or combinations that put the patient at high risk for overdose
10. When prescribing opioids for subacute or chronic pain, clinicians should consider the benefits and risks of toxicology testing to assess for prescribed medications as well as other prescribed and nonprescribed controlled substances
11. Clinicians should use particular caution when prescribing opioid pain medication and benzodiazepines concurrently and consider whether benefits outweigh risks of concurrent prescribing of opioids and other central nervous system depressants
12. Clinicians should offer or arrange treatment with evidence-based medications to treat patients with opioid use disorder.
    1. Detoxification on its own, without medications for opioid use disorder, is not recommended for opioid use disorder because of increased risks for resuming drug use, overdose, and overdose death

Source:

1. Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. MMWR Recomm Rep 2022;71(No. RR-3):1–95.

Prescription opioids are often used to treat chronic and acute pain and, when used appropriately, can be an important component of treatment. However, taking prescription opioids for longer periods of time or in higher dosages can increase the risk of opioid use disorder, overdose, and death. It is also important for patients and providers to discuss the risks of opioids, consider alternative therapies, and, if prescribing opioids is appropriate, the provider should offer fewer prescriptions for fewer days and at lower dosages (1).

In 2018, there were approximately 51 opioid prescriptions written for every 100 Americans.

• 15% of Americans had at least one opioid prescription filled, with an average of 3.4 opioid prescriptions dispensed per patient.
• Per prescription, the average daily amount was more than 42.9 MME.
• The average number of days per prescription continues to increase, with an average of 18 days in 2018 (2).

From 1999 to 2021, nearly 280,000 people died in the United States from overdoses involving prescription opioids. The number of drug overdose deaths involving prescription opioids in 2021 was nearly five times the number in 1999.

In 2021, 45 people died each day from a prescription opioid overdose, totaling nearly 17,000 deaths.1 Prescription opioids were involved in nearly 21% of all opioid overdose deaths in 2021 (3).

Sources 

1. Centers for Disease Control and Prevention. (n.d.). Prescribing Practices. U.S. Department of Health and Human Services.
2. Centers for Disease Control and Prevention. (2019) 2019 Annual Surveillance Report of Drug-Related Risks and Outcomes — United States Surveillance Special Report. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services.
3. Centers for Disease Control and Prevention. (n.d.). Opioid Overdose. U.S. Department of Health and Human Services. 

IDOH Overdose Prevention Records