Opioid-Related Deaths in the Kansas City Area
Jackson County Medical Examiner’s office points to oxycodone, heroin, fentanyl as leading causes
By Robert Pietak, MD; Marius Tarau, MD; and Lindsey Haldiman, DO
Opioids are a class of drugs that include the illicit drug heroin as well as the prescription pain relievers oxycodone, hydrocodone, codeine, morphine, fentanyl and other synthetic analogues just to name a few. Opioid drugs, typified by morphine, produce their pharmacological actions, including analgesia, by acting on receptors located on neuronal cell membranes. The presynaptic action of opioids to inhibit neurotransmitter release is considered to be their major effect on the nervous system. Deaths are usually attributed to respiratory depression.
In the U.S. the highest drug death rates are among individuals ages 25 to 54. The Centers for Disease Control and Prevention reports the age-adjusted death rate from overdoses more than tripled from 1999 to 2016.1 This has been a major issue for medical examiner offices in larger metropolitan cities throughout the United States. The crisis results in an increased workload for the forensic pathologist and puts a strain on the annual operating office budgets to cope with the increased laboratory analysis costs.
With the constant occurrence of newly formed synthetic-related opioid compounds, it becomes a challenge to identify the presence of these drugs in the body. go undiagnosed until adequate toxicological analysis can be developed to identify these new analogues. The Jackson County Medical Examiner’s Office (JCMEO) takes jurisdiction of cases from Jackson, Cass, Clay and Platte counties, covering an overall population of approximately 1.2 million. We examined the opioid-related deaths in our office for the years 2013 to 2017.
On average our office investigates around 104 deaths per year due to opioids and 29 deaths per year due to non-opioid prescription drugs deaths. Consequently, the fatality rate due to opioids is approximately 11 per 100,000 population compared to 4 per 100,000 population for non-opioid prescription drugs.
OXYCODONE LEADING CA– USE 2013- 2015
From 2013–2015, the JCMEO handled 332 opioid-related deaths, the majority of which were classified as accidents in terms of the manner of death with a minority (7 to 13 per year) classified as suicides. Less common additional opioid-related fatalities included one natural, one as an undetermined, one an accident/traffic and one as homicide during the same years. The death ruled as homicide involved an individual who was using opioids for chronic pain syndrome secondary to a remote gunshot wound to the neck.
During this period, the most frequent fatal opioid drug in our population (in Jackson County and overall in our jurisdiction) was oxycodone, followed by, in order, hydrocodone, methadone and morphine. The most affected age group was 51 to 60 years followed by 41 to 50 years and 31 to 40 years, with males more affected than females. For this same period, opioid-related deaths accounted for 13% of non-natural deaths (or 28% if you exclude traffic fatalities). For comparison, in the same time interval of 2013–2015, homicides and traffic accidents accounted for 16% and 13% of all non-natural deaths, respectively. Overall, opiates were responsible for almost 60% of drug-related deaths in our population, representing more than 7% of total cases of in which we assumed jurisdiction.
OPIOID-RELATED DEATHS IN 2016
In 2016, opioids deaths represented 6% of JCMEO cases. There was a total of 98 opioid-related fatalities, 18 of which involved heroin. Of those 98 cases, the manner of death was ruled accidental in 91 cases and suicide in 7 cases (one case involved a traffic accident in which opioid use was a contributing factor). Oxycodone again was the most frequent fatal opioid drug. In contrast to 2013–2015 opioid-related deaths, fentanyl was found to be the second most frequent opioid drug involved, followed by heroin, hydrocodone, morphine and methadone.
Most of the opioid-related deaths in 2016 involved multiple drugs. Thirty-two of the 98 opioid-related deaths involved single drug use, the most frequent of which was heroin followed by oxycodone and fentanyl in that order. A total of 13 individuals died from exclusive heroin use, the majority of which were white males with an average age of 38 years.
Preliminary examination of opioid-related deaths in 2017 revealed the investigation of a total of 92 opioid-related deaths within the jurisdiction of the JCMEO. The majority of individuals were white males with an average age of 42 years. Interestingly, the most frequent fatal opioid drug involved was now heroin, accounting for 31 deaths followed by oxycodone accounting for 20 deaths. Both fentanyl and hydrocodone were each implicated in 10 deaths. Multiple drugs contributing accounted for the remaining 31 deaths.
DEATHS FROM HEROIN AND FENTANYL INCREASING
Opioid abuse is a major problem in the United States and has resulted in numerous deaths throughout the nation. At the JCMEO, the overall percentage of deaths related to opioids for the past five years has not significantly changed. However, we have seen a definite rise in deaths in which heroin and fentanyl are implicated. Oxycodone continues to be a major player in opioid-related deaths. Our data is in keeping with that seen nationwide in which white males from their 30s and 50s seem to be at the highest risk of death related to opioid use.
At the JCMEO, our medico-legal death investigators are trained to collect a detailed history from family and friends as well as examine the death scene for drug paraphernalia. Consequently, the majority of opioid-related deaths are suspected prior to autopsy. However, this is not always the case. Our office performs toxicology testing on every decedent brought into our office to ensure that drug-related deaths are not missed. Unfortunately, toxicology testing for newly developed synthetic opioid compounds, particularly fentanyl analogues, continue to be a challenge for our office as well as offices nationwide requiring expensive send-out testing. At the same time, the Centers for Disease Control and Prevention estimates that the total “economic burden” of prescription opioid misuse alone in the United States is $78.5 billion a year, including the costs of health care, lost productivity, addiction treatment and criminal justice involvement.
- Hedegaard H, Warner M, Miniño AM. Drug overdose deaths in the United States, 1999–2016. NCHS Data Brief, no 294. Hyattsville, MD: National Center for Health Statistics. 2017.
- Florence CS, Zhou C, Luo F, Xu L. The Economic Burden of Pre- scription Opioid Overdose, Abuse, and Dependence in the United States, 2013. Med Care. 2016;54(10):901-906.