Abstract
This cross-sectional study examines excess mortality, measured as years of life lost, associated with unintentional drug overdose in Ohio from 2009 to 2018.
Introduction
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
Methods
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.
Results
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.
Figure. Top 6 Causes of Excess Mortality in Years of Life Lost in Ohio in 2017.
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.
Table. Annual Trends in All-Cause Mortality and the Top 3 Causes of Excess Mortality in Ohio From 2009 to 2018.
| Factor | 2009 | 2010 | 2011 | 2012 | 2013 | 2014 | 2015 | 2016 | 2017 | 2018 |
|---|---|---|---|---|---|---|---|---|---|---|
| All deaths | ||||||||||
| Deaths, No. | 107 061 | 108 458 | 110 705 | 112 049 | 112 915 | 114 343 | 118 014 | 119 574 | 123 650 | 123 596 |
| Total YLL | 1 607 512 | 1 600 450 | 1 628 744 | 1 646 358 | 1 662 433 | 1 686 541 | 1 756 972 | 1 821 864 | 1 893 923 | 1 836 220 |
| YLL per death, mean (SD) | 15.0 (13.0) | 14.8 (12.9) | 14.7 (12.9) | 14.7 (12.8) | 14.7 (12.8) | 14.7 (12.7) | 14.9 (12.9) | 15.2 (13.2) | 15.3 (13.2) | 14.9 (12.8) |
| Age at death, mean (SD), y | 73.1 (17.8) | 73.6 (17.8) | 73.6 (17.8) | 73.7 (17.7) | 73.6 (17.7) | 73.5 (17.6) | 73.4 (17.9) | 72.9 (18.2) | 72.8 (18.2) | 73.4 (17.8) |
| Malignant neoplasm | ||||||||||
| Deaths, No. | 25 076 | 25 030 | 24 967 | 25 199 | 24 918 | 25 390 | 25 367 | 25 507 | 25 647 | 24 771 |
| Total YLL | 399 244 | 393 169 | 391 473 | 396 489 | 393 441 | 399 724 | 396 571 | 395 538 | 397 670 | 380 924 |
| YLL per death, mean (SD), y | 15.9 (9.7) | 15.7 (9.6) | 15.7 (9.5) | 15.7 (9.6) | 15.8 (9.5) | 15.7 (9.4) | 15.6 (9.4) | 15.5 (9.3) | 15.5 (92) | 15.4 (9.1) |
| Age at death, mean (SD), y | 70.7 (13.5) | 71.1 (13.5) | 71.1 (13.4) | 71.0 (13.4) | 70.9 (13.3) | 71.0 (13.3) | 71.1 (13.2) | 71.3 (13.2) | 71.3 (13.0) | 71.4 (12.9) |
| Heart disease | ||||||||||
| Deaths, No. | 25 898 | 26 072 | 26 179 | 26 304 | 26 761 | 26 934 | 28 026 | 27 407 | 28 000 | 28 708 |
| Total YLL | 311 390 | 311 112 | 309 676 | 315 205 | 320 219 | 322 056 | 334 268 | 333 110 | 338 526 | 340 428 |
| YLL per death, mean (SD) | 12.0 (9.5) | 11.9 (9.4) | 11.8 (9.3) | 12.0 (9.5) | 12.0 (9.4) | 12.0 (9.4) | 11.9 (9.4) | 12.2 (9.5) | 12.1 (9.4) | 11.9 (9.2) |
| Age at death, mean (SD), y | 77.3 (14.6) | 77.4 (14.6) | 77.6 (14.5) | 77.4 (14.6) | 77.4 (14.7) | 77.4 (14.6) | 77.5 (14.6) | 77.1 (14.8) | 77.2 (14.6) | 77.6 (14.5) |
| All overdose deaths | ||||||||||
| Deaths, No. | 1389 | 1511 | 1720 | 1864 | 2065 | 2476 | 2986 | 3939 | 4786 | 3614 |
| Total YLL | 53 720 | 58 574 | 65 693 | 72 117 | 78 737 | 96 595 | 117 738 | 155 632 | 187 006 | 141 008 |
| YLL per death, mean (SD) | 38.7 (10.9) | 38.8 (11.2) | 38.2 (11.1) | 38.7 (10.8) | 38.1 (11.1) | 39.0 (11.1) | 39.4 (11.1) | 39.5 (11.2) | 39.1 (11.3) | 39.0 (11.4) |
| Age at death, mean (SD), y | 41.8 (13.3) | 41.7 (13.3) | 42.4 (13.3) | 41.7 (12.8) | 42.3 (13.3) | 41.3 (13.3) | 40.8 (13.2) | 40.7 (13.2) | 41.2 (13.4) | 41.3 (13.5) |
| Opioid-involved overdose deaths | ||||||||||
| Deaths, No. | 780 | 978 | 1130 | 1239 | 1511 | 1989 | 2565 | 3423 | 4112 | 3066 |
| Total YLL | 31 115 | 38 693 | 44 354 | 49 475 | 59 116 | 78 879 | 103 488 | 137 382 | 163 407 | 121 689 |
| YLL per death, mean (SD) | 39.9 (10.4) | 39.6 (11.1) | 39.3 (10.8) | 39.9 (10.6) | 39.1 (10.8) | 39.7 (10.9) | 40.3 (10.7) | 40.1 (11.0) | 39.7 (11.0) | 39.7 (11.0) |
| Age at death, mean (SD), y | 40.3 (12.5) | 40.7 (13.3) | 41.1 (12.7) | 40.2 (12.4) | 41.0 (12.8) | 40.5 (12.9) | 39.8 (12.6) | 40.0 (12.8) | 40.4 (12.9) | 40.5 (12.9) |
| Non–opioid-involved overdose deaths | ||||||||||
| Deaths, No. | 609 | 533 | 590 | 625 | 554 | 487 | 421 | 516 | 674 | 548 |
| Total YLL | 22 605 | 19 881 | 21 339 | 22 642 | 19 621 | 17 716 | 14 249 | 18 250 | 23 599 | 19 320 |
| YLL per death, mean (SD) | 37.1 (11.3) | 37.3 (11.1) | 36.2 (11.2) | 36.2 (10.9) | 35.4 (11.5) | 36.4 (11.6) | 33.8 (11.7) | 35.4 (11.7) | 35.0 (12.2) | 35.3 (12.8) |
| Age at death, mean (SD), y | 43.8 (13.9) | 43.5 (13.1) | 45.0 (13.8) | 44.7 (13.0) | 45.6 (14.1) | 44.7 (14.2) | 47.5 (14.3) | 45.6 (14.4) | 46.0 (14.7) | 46.0 (15.4) |
Abbreviation: YLL, years of life lost.
Discussion
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.
References
- 1.Gomes T, Tadrous M, Mamdani MM, Paterson JM, Juurlink DN. The burden of opioid-related mortality in the United States. JAMA Netw Open. 2018;1(2):-. doi: 10.1001/jamanetworkopen.2018.0217 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Scholl L, Seth P, Kariisa M, Wilson N, Baldwin G. Drug and opioid-involved overdose deaths—United States, 2013-2017. MMWR Morb Mortal Wkly Rep. 2018;67(5152):1419-1427. doi: 10.15585/mmwr.mm675152e1 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Hall OT, Hall OE, McGrath RP, Haile ZT. Years of life lost due to opioid overdose in Ohio: temporal and geographic patterns of excess mortality. J Addict Med. Published online October 7, 2019. doi: 10.1097/ADM.0000000000000554 [DOI] [PubMed] [Google Scholar]
- 4.Ohio Alliance for Innovation in Population Health Years of lost life: overdose deaths 2009-2018. Accessed February 28, 2020. https://878570bd-c4fe-4dfe-8107-669a96dd214b.filesusr.com/ugd/89e8f1_6f36fea2f1894e46aed077a0627237f2.pdf
- 5.Social Security Administration Actuarial Life Table: Period Life Table, 2014. Accessed February 28, 2020. https://www.ssa.gov/oact/STATS/table4c6_2014.html
- 6.Centers for Disease Control and Prevention Stats of the state of Ohio. April 2018. Accessed October 24, 2019. https://www.cdc.gov/nchs/pressroom/states/ohio/ohio.htm