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Public Health Rep. 2018 Jul/Aug;133(4):423-431. doi: 10.1177/0033354918774330. Epub 2018 Jun 27.

The Effect of Incomplete Death Certificates on Estimates of Unintentional Opioid-Related Overdose Deaths in the United States, 1999-2015.

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1 Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA.
2 Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
3 Office of the Medical Examiner of Allegheny County, Pittsburgh, PA, USA.
4 Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA.



A complete and accurate count of the number of opioid-related overdose deaths is essential to properly allocate resources. We determined the rate of unintentional overdose deaths (non-opioid-related, opioid-related, or unspecified) in the United States and by state from 1999 to 2015 and the possible effects of underreporting on national estimates of opioid abuse.


We abstracted unintentional drug overdose deaths ( International Classification of Diseases, 10th Revision, codes X40-X44) with contributory drug-specific T codes (T36.0-T50.9) from the Mortality Multiple Cause Micro-Data Files. We assumed that the proportion of unspecified overdose deaths that might be attributed to opioids would be the same as the proportion of opioid-related overdose deaths among all overdose deaths and calculated the number of deaths that could be reallocated as opioid-related for each state and year. We then added these reallocated deaths to the reported deaths to determine their potential effect on total opioid-related deaths.


From 1999 to 2015, a total of 438 607 people died from unintentional drug overdoses. Opioid-related overdose deaths rose 401% (from 5868 to 29 383), non-opioid-related overdose deaths rose 150% (from 3005 to 7505), and unspecified overdose deaths rose 220% (from 2255 to 29 383). In 5 states (Alabama, Indiana, Louisiana, Mississippi, and Pennsylvania), more than 35% of unintentional overdose deaths were coded as unspecified. Our reallocation resulted in classifying more than 70 000 unspecified overdose deaths as potential additional opioid-related overdose deaths.


States may be greatly underestimating the effect of opioid-related overdose deaths because of incomplete cause-of-death reporting, indicating that the current opioid overdose epidemic may be worse than it appears.


death; death certificates; drug overdose; epidemics; opioids

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