Trends in psychotropic-drug-implicated mortality: Psychotropic drugs as a contributing but non-underlying cause of death
Introduction
The United States experienced considerable growth in fatal overdoses over the past 20 years, which contributed greatly to years of life lost (Case and Deaton, 2014; Dowell et al., 2017; Ho, 2017; Imtiaz et al., 2018; Jalal et al., 2018) and to broader societal costs (Birnbaum et al., 2011). Opioids have been a primary driver of increasing overdoses, unfolding in three waves corresponding to mortality associated with prescription opioids followed by heroin and most recently synthetic opioids such as fentanyl (Ciccarone, 2019). Furthermore, overdose deaths from other prescription medications, such as benzodiazepines and stimulants, as well as cocaine and methamphetamine have also escalated (Bachhuber et al., 2016; Scholl et al., 2019). In this article, we examine whether the burden of the drug mortality crisis has grown even wider than overdose mortality indicates. By analyzing mortality data in which psychotropic drugs were a contributing but not the underlying cause of death, we consider the degree to which the drug mortality crisis extends beyond individuals lost to overdoses, and how such non-overdose deaths may even temper recent reductions in other causes of mortality.
Drug overdose deaths are often contrasted with other categories of mortality to demonstrate their impact on population health. For example, a common refrain is that opioid overdoses now account for more deaths annually than motor vehicle accidents (Hedegaard et al., 2015; Jones et al., 2015; Rudd et al., 2016; Unick et al., 2013). Indeed, external causes of death including motor vehicle fatalities (Sauber-Schatz et al., 2016; Weast, 2018), non-drug-induced poisoning deaths such as those due to carbon monoxide (Hampson, 2016), and drownings (Umapathi et al., 2020) have declined during the period in which drug overdoses have increased. Such declines are not limited to external causes of death; rates of medical causes of death have also decreased, including two leading causes of death in the U.S. Deaths from diseases of the circulatory system declined considerably since 2000, including among all major categories such as cardiovascular disease, heart disease, and stroke and across gender and racial groups (Sidney et al., 2016). Deaths from cancer also declined over the same period (Sidney et al., 2016; Curtin, 2019). By contrast, other categories of deaths have increased alongside drug overdoses during the past two decades, including suicide (Rossen et al., 2018), deaths attributable to falls (Burns and Kakara, 2018; Peterson and Kegler, 2020), and deaths attributable to alcohol (White et al., 2020). However, drug overdoses are often contrasted with these other causes of death as if independent. Instead, drug use and dependence must be considered together with their contribution to the burden of morbidity and mortality more generally (Degenhardt and Hall, 2012).
The U.S. CDC categorizes drug-related deaths in a manner that focuses on drugs as the underlying cause of death rather than a wider scope of deaths in which psychotropic drugs are implicated as a contributing factor. The CDC’s definition of drug overdose mortality requires that poisoning from the drug is the underlying cause of death to be counted as an overdose. These deaths have ICD-10 underlying cause of death codes for “drug poisoning” (see methods section) and are not limited to psychotropic drugs. Also, in some tabulations, overdose deaths are combined with particular ICD codes and termed “drug-induced mortality” (Kochanek et al., 2019). However, these deaths can also be due to any substance whether psychotropic or not, only apply to a specific set of ICD codes, and do not include any non-poisoning external causes of death where psychotropic drugs may have been a factor.
These constraints, together with considerable focus on overdose deaths in scientific and media representations of the problem, obscures how growth in psychotropic drug-related problems have shaped patterns of mortality beyond overdose as an underlying cause of death. In this article, we focus on deaths in which psychotropic drugs were a contributing but not underlying cause of death, which we refer to as “psychotropic-drug-implicated deaths.” By examining the co-occurrence of deaths due to other causes involving a psychotropic drug, we gain clarity into the greater toll of the current drug-related mortality crisis beyond overdose deaths. In this article, we assess trends in psychotropic-drug-implicated deaths since 1999 and how this varies by the underlying cause of death. Countervailing trends may impede improvements otherwise experienced for certain causes of death or exacerbate causes of death that are increasing.
Section snippets
Methods
We utilized CDC WONDER Multiple Cause of Death data for a twenty-one-year period, 1999−2019, which contains every death in the U.S. Cause of death codes allowed identification of the “underlying cause” as well as any other cause (“multiple cause”) implicated in the death (up to 10). The CDC classifies drug overdoses as those with ICD-10 underlying cause of death codes for “drug poisoning” (X40-X44, X60-X64, X85, and Y10-Y14). Thus, the CDC definition includes all substances that lead to
Age-adjusted death rates over time
Fig. 1 shows trends in all deaths and by medical and external causes of death in which a psychotropic drug was implicated. The lines represent age-adjusted death rates per 100,000, while the table beneath shows the number of deaths. An increasing trend is immediately clear. From 1999–2019, the rate of annual psychotropic-drug-implicated medical deaths increased 2.5 times from 0.31 to 0.78 per 100,000. During the same period, the rate of annual psychotropic-drug-implicated external deaths
Discussion
It is well recognized that overdose has contributed greatly to early mortality in the U.S. during the 21st century (Birnhaum et al. 2011; Case and Deaton, 2014; Dowell et al., 2017; Ho, 2017; Imtiaz et al., 2018; Jalal et al., 2018). In this article, we focused on psychotropic-drug-implicated mortality, which includes deaths where a psychotropic drug was listed as a contributing (not underlying) cause of death. We contend that this permits a broader picture of the toll of the drug mortality
Contributors
Vuolo and Kelly conceptualized and designed the study, acquired grant funding, conducted data analysis, drafted the initial manuscript, and reviewed and revised the manuscript.
Frizzell conducted data coding and analysis and reviewed and revised the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
Funding source
This work was funded by the National Institute on Drug Abuse (grant # R21DA046447). The funding agency had no role in the research; the views expressed in this paper do not represent those of the funding agency.
Declaration of Competing Interest
The authors report no declarations of interest.
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2023, American Journal of Preventive Medicine