Heroin overdose deaths could be undercounted
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* Julia Haskins

Deaths from opioid overdoses involving heroin may be greatly undercounted, according to a study looking at such fatalities in Marion County, Indiana.

The study, published online in January in the *Journal of Urban Health*, sought to determine the number of people who died of a drug overdose with heroin in their system, as opposed to the number who died of a heroin overdose, according to Brad Ray, PhD, MA, assistant professor in the School of Public and Environmental Affairs at Indiana University-Purdue University Indianapolis.

Such a distinction is important to make because deaths involving multiple drugs are reported only as polydrug-related and do not mention if heroin is present. Sometimes toxicology reports do not account for the presence of heroin because the drug quickly metabolizes into natural opioids, meaning there may only be signs of morphine and codeine. Understanding which opioids are involved in polydrug deaths can help identify trends in substance use throughout the state, according to Ray.

He and colleagues examined death certificates and toxicology reports for accidental drug overdose deaths in Marion County from 2010 to 2015. While the Marion County Health Department recorded 141 deaths from heroin during this time period, study researchers determined 455 of the 1,199 deaths analyzed were related to heroin.

Overall, 918 cases involved an opioid, including heroin, morphine, codeine, oxycodone, hydrocodone, oxymorphone, hydromorphone and fentanyl.

Throughout the six-year time period, the total number of drug overdoses increased from 129 to 260, with opioid-related drug overdose deaths also increasing. Heroin was present in nearly half of all cases, followed by hydrocodone and hydromorphone, each present in about one-quarter of all cases.

Drug-related overdoses are the leading cause of injury-related death in the U.S., according to the study. Many states have succumbed to the opioid crisis, especially in the Rust Belt, but there are problems with opioid misuse specific to Indiana, according to Ray.

“We’ve been slow to embrace evidence-based treatment modalities,” Ray told The Nation’s Health, citing deficiencies in treatment such as a dearth of methadone centers and few harm-reduction solutions, including syringe exchanges.

Further, Ray said, better utilizing data from the Indiana Prescription Drug Monitoring Program could help identify areas for improvement and pinpoint health care providers who are overprescribing opioids.

“Doctors need to be educated on the dangers of overprescribing and also their ability to help curb this epidemic,” Ray said.

However, he said, policies must also focus on illicit drug use, as so many non-prescription drugs are responsible for overdose deaths in Indiana. A focus on illicit drug use is particularly pressing, with more users turning to illicit opioids as the availability of prescription opiates dwindles — a trend in Marion County that reflects current drug use patterns, according to the study.

Several measures have had a positive impact on the opioid crisis in Indiana, the study stated, including two pieces of legislation: one to shut down pill mills and another providing funding to the Indiana Prescription Drug Monitoring Program to allow prescribers, dispensers and law enforcement to implement new guidelines for prescribing controlled substances.

The study cautioned against both deregulating prescription opiates and bolstering law enforcement in response to the opioid crisis in Indiana, and instead called for expanded treatment in the state.

For more information, visit [www.link.springer.com/article/10.1007%2Fs11524-016-0113-2](http://www.link.springer.com/article/10.1007%2Fs11524-016-0113-2).

*   Copyright The Nation’s Health, American Public Health Association