The Massachusetts
Opioid Epidemic

A data visualization of findings from the Chapter 55 report

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A Deadly Problem

Massachusetts is currently experiencing an epidemic of opioid-related overdose and death.

These overdoses are driven by the underlying chronic disease of opioid addiction or opioid use disorders. People with opioid addiction are at high risk of overdose and death.

Opioid-related deaths in the state were more than four times higher in 2015 than in 2000. This recent rate of increase is several times faster than anything seen here before. In 2013–2014 alone, opioid-related deaths occurred in two-thirds of the cities and towns in Massachusetts.

Average Annual Opioid-related Death Rate per 100,000 Peoplesee footnote1,see footnote2,see footnote3,see footnote4,see footnote5

The maps below, representing average annual rates of opioid-related deaths across five-year spans, demonstrate the increase in both the spread and intensity of the problem across Massachusetts.

The opioid-related death rate in Massachusetts has surpassed the national average, with an especially sharp rise in the last two years.

In fact, 2014 marked the first year since 1999see footnote6 that the fatal overdose rate in the Bay State was more than double the national average. While opioid-related deaths have been on the rise across the country during that period, the situation in the Commonwealth has become especially worrying.

In one way or another — through deaths, nonfatal overdoses, or disruptions to jobs, marriages, families, and neighborhoods — every community in Massachusetts has been impacted by this growing crisis.

Age-Adjusted Opioid-related Death Rate by Yearsee footnote4,see footnote7,see footnote8

Comparing the opioid-related death rate of Massachusetts to the nation overall.

Sources: Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple Cause of Death 1999-2014 on CDC WONDER Online Database, released 2015. Massachusetts Registry of Vital Records and Statistics, Massachusetts Department of Public Health.

Understanding the causes and deadly effects of this issue can be a challenge. It’s a complex problem that has many layers and no single solution. It often raises more questions than answers. Why do people start — and why do they continue – taking opioids? How many people does this affect? What can be done about it and what steps are being taken? What is an opioid, anyway?

Definition
The term opioid means “opiate-like.” It generally refers to a family of substances that include natural opiates (like Morphine and Codeine), as well as synthetic and semi-synthetic opioids like Heroin, Oxycodone, and Fentanyl.
Uses
The most common medical use of opioids is in the treatment of pain across a broad spectrum, from acute post-surgical pain, to chronic pain in cancer patients, to end-of-life care. Opioids can also be misused, like taking a higher dosage of a painkiller than what a doctor prescribed. Other types of misuse can be unlawful, including taking heroin — which is illegal in all instances — or taking Oxycodone that has been legally prescribed to another person. This latter behavior, transferring drugs prescribed for one person to be used by someone else, is known as “diversion”.
Side Effects
Short-term side effects include drowsiness, depressed breathing, and euphoria. Long-term usage can trigger the body to develop tolerance, dependence, and addiction.
  • Tolerance is the body’s natural response to the regular presence of a substance, requiring higher doses to achieve the same effect.
  • Dependence occurs when the body becomes so accustomed to the presence of a substance that its sudden absence causes withdrawal. For an opioid user, that could also mean that a prescription to address localized pain (a shoulder, a knee, a back) could cause pain all over the body if the prescription ends without tapering off.
  • Addiction is a complex brain-body disease, where brain and body responses have changed to negatively and drastically affect behavior. This often includes an irresistible compulsion for short-term relief even in the face of both immediate and long-term risk.
Each side effect is independent of the others, meaning that any, all, or none may occur in any individual.

Chapter 55

In the face of this emergent public-health issue, the Commonwealth of Massachusetts took an unprecedented deep dive into available data on opioid-related deaths to investigate the crisis. As part of a multi-faceted effort to combat the epidemic, Chapter 55 of the Acts of 2015 was passed by the Legislature and signed into law by Governor Baker in August 2015.

This new law permits the analysis of different government datasets to guide policy decisions and to better understand the opioid epidemic. Recently, a groundbreaking report highlighting the current state of the crisis was released as part of this effort.

Led by the Department of Public Health (DPH), the Chapter 55 analysis involved 10 datasets from five different government agencies. In total, 29 groups from government, higher education, and the private sector provided information and expertise. This level of partnership is what makes the Chapter 55 report a milestone achievement in Massachusetts. Before this legislation was passed, such a comprehensive look at the opioid epidemic in the Commonwealth would not have been possible.

In addition to providing significant insights into the opioid crisis by answering seven key questions, this project demonstrates how private and public organizations can collaborate to answer complex public-health questions. This model of cooperative data analysis has the potential to become the standard in Massachusetts and across the United States. The Chapter 55 project represents a process that should be continued, adapted, and refined as new public health challenges and new collaborators step forward.

Below are examples of opioid use trends that were uncovered by Chapter 55 analysis. Real, actionable steps to curb the epidemic can be taken as a direct result of this innovative data effort.

Addiction and Substance Use Disorder

Similar to diabetes or cancer, addiction is a complex disease impacted by certain risk factors like behavior and family history. Compulsive substance abuse, cravings, and continued use despite known harmful consequences are hallmarks of the condition. This disease is also more widespread than some may realize — according to a study from the Substance Abuse and Mental Health Services Administration (SAMHSA), nearly 1 in 12 Americans over the age of 12 have a substance abuse disorder.

Cost of Addiction

Economically, addiction is more costly than other brain conditions like Alzheimer’s disease, Parkinson’s disease, and stroke. In fact, data from the National Institutes of Health (NIH) shows that costs related to substance abuse top more than $700 billion annually in the United States.

However, economic impact is hardly the most negative aspect of addiction and, more specifically, the opioid epidemic. Addiction to opioids can put people at greater risk for infectious diseases like HIV or hepatitis, deteriorating conditions like cirrhosis or cognitive decline, family disruption like domestic violence or child abuse, job loss, exposure to criminal behavior, overdose, and death.

Growth of Addiction in Massachusetts

Data from the DPH Bureau of Substance Abuse Services (BSAS) shows an increasing need for opioid-related treatment in Massachusetts. In 2000, about one third of admissions to substance abuse treatment centers and programs were opioid-relatedsee footnote9. By 2015, that figure had increased to more than half, overtaking alcohol as the most prevalent substance recorded by BSAS at treatment intake. The Health Policy Commission (HPC) recorded similar numbers for emergency room visits and hospitalizations during that time.

Along with the rise in demand for opioid use treatment, nationally and in Massachusetts, there has been an increase in opioid-related overdoses, both fatal and nonfatal.

Primary Substance of Use When Entering Treatment by Townsee footnote9,see footnote10,see footnote11,see footnote12,see footnote13

At admission, clients identify a primary substance of use for which they are seeking treatment. Below, view the changes in the percentage of primary substances identified at admission from 2000 to 2015.


Filter by town name or

Percentage of Patients in Treatment Listing Heroin as their Primary Substance of Usesee footnote11,see footnote12,see footnote13

At admission, clients identify a primary substance of use for which they are seeking treatment. Below, view maps at five-year intervals which show the increase in the percentage of admissions identifying heroin as their primary substance of use.


Substance Use

Opioids are incredibly powerful drugs that have transformed the way the health care world treats and manages pain. However, because they are so potent, they can be dangerous if misused. To understand the opioid epidemic, it’s important to realize how both legal prescription medications and illegal substances impact the crisis in Massachusetts. To investigate the scope of the problem, the entire population of adultssee footnote14 was analyzed.

Prescriptions

The number of opioids prescribed to residents of Massachusetts has increased roughly 7% annually since 2000. In 2015, nearly one in six Massachusetts residents obtained an opioid prescription from a health care provider. Those receiving prescriptions obtained more than three filled prescriptions on average.

Prescription History for Fatal Overdoses

About 8 in 12 people who died from opioids in 2013 and 2014 had an opioid prescription at some point from 2011–2014

Only about 1 in 12 people who died from opioids in 2013 and 2014 had an active opioid prescription in the month before they died

Whether using them for legitimate medical reasons or not, anyone can become dependent on or addicted to opioids. When this happens, the body’s craving for an opioid continues even if a prescription runs out. In these cases, many people keep using opioids, but illegally. More than two-thirds of people who died from an opioid-related overdose had a legal opioid prescription at some point from 2011–2014. However, only about 1 in 12 of those who died had an opioid prescription in the month before their death.

It should be noted that opioid-related deaths began increasing sharply in 2012, no similar increase in opioid prescriptions was recorded. This suggests that no single substance or health care practice is solely responsible for the current opioid crisis. Rather, it’s a complex issue with a number of contributing factors.

Deadly Trend: Switching from Legal to Illegal Opioids

Some people make the transition from legal to illegal opioid use, driven by the disease of addiction. This becomes clear by looking at the amount of people who had a prescription six months, three months, and one month before death. This is found regardless of the substance that caused a fatal overdose.

Multiple Prescribers

One risk factor for fatal overdose that was identified was the number of opioid prescribers for an individual. There are legitimate reasons why someone might have multiple prescribers — primary care plus specialistssee footnote18 or multi-provider practicessee footnote19 — but there is an elevated risk for this group. The fatal opioid-related overdose rate for individuals with three or more opioid prescribers is seven times higher than the rate for other people.

Multiple Substances

Using multiple substances at the same time is also a risk factor. For example, Cocaine showed up in 30% of toxicology screens for opioid-related deaths from 2013–2014. Nearly 60% of post-mortem toxicology screens were positive for benzodiazepines. Benzodiazepines are a type of tranquilizer, including drugs like Valium, Xanax, and Ativan, and are typically used to treat anxiety.

While Cocaine is always illegal, benzodiazepines are legally available but might be used outside a prescription. Although benzodiazepines were present in nearly 1,000 toxicology screens from 2011–2014, only about half that many people ever had a prescription for one during that period. Fewer than 200 had a benzodiazepine prescription within a month of death. This suggests that the supply of benzodiazepines involved in overdoses includes both prescribed and diverted pills.

Illegal Drugs

When it comes to illegal opioids, Massachusetts is facing a dangerous combination of trends. Some individuals are transitioning from legal to illegal opioid use, perhaps due to dependence and addiction developing beyond prescribed thresholds. At the same time, the availability of illegal drugs is strengthening across the region. The Drug Enforcement Administration (DEA) surveyed law enforcement officials about the availability of Heroin in eight regions across the country from 2007 to 2014see footnote20. Each year, New England led all regions in the percentage of respondents who reported high Heroin availability

Heroin, perhaps expectedly, is commonly found in toxicology reports for opioid-related deaths. Data from 2013–2014 shows Heroin was likely or definitely in the individual's system at the time of death in more than 60% of opioid-related overdose deaths. What might be surprising is the increasingly deadly role Fentanyl is playing in the crisis.

While Fentanyl can be available as a legally-prescribed medication, it is most often used illegally. Only about 3% of people who died from an opioid-related overdose and had Fentanyl present in their toxicology screen during the study period had a prescription for Fentanyl at the time of death. However, toxicology data shows Heroin, Fentanyl, or both substances were present in 85% of cases.

Fentanyl: Legal and Illegalsee footnote16

Fentanyl is an opioid that can be prescribed for pain management. However, it’s also used illegally either on its own or combined with Heroin, often without the user's knowledge. According to the DEA, illegally produced Fentanyl can be up to 50 times more potent than Heroin. Fentanyl is increasingly recognized as a problem across the United States, and particularly in Massachusetts. Toxicology data from recent post-mortem cases indicates Fentanyl is adding to the state’s deadly epidemic more than Heroin. In 2015, more than 60% of toxicology samples tested positive for Fentanyl. In the previous year, that mark was about 40%.

Demographics

Opioid addiction doesn’t discriminate. The crisis in Massachusetts affects people from all backgrounds. The widespread nature of the epidemic makes addressing it an especially challenging task, because the path to opioid addiction has different starting points from person to person. While definite solutions might still be a mystery, knowing how the epidemic plays out among different sections of society can help Massachusetts find ways to strongly and effectively address this problem.

Male and Female

Despite the fact more men die from opioid overdoses than women, both genders are at risk, yet in different ways. Toxicology reports show men are more likely than women to have Heroin in their systems, while prescription opioids are more likely to be found in women than in men at the time of death. Part of this discrepancy may be down to a simple fact — women are more likely to use the health care system. This could present a particular risk for women because they are also more likely than men to have multiple prescribers for opioids, which is a risk factor as mentioned above.

Prescriber and Opioid Use Trends by Gendersee footnote21


person icon= 1% of 1,692 Opioid-related Deaths from 2013-2014

Young People

The fight to curb the opioid epidemic in Massachusetts is also a battle to protect future generations. The percentage of opioid-related deaths for different age groups shows the young people of Massachusetts are especially at risk. From 2013–2014, opioids accounted for more than a quarter of all fatalities in the 18–24 age group. For individuals from 25–34, opioids were responsible for more than a third of all deaths, rising to more than 40% for men in this group. In 2015, roughly two out of every three people who died from opioids were younger than 45.

Fatal Opioid Overdoses by Age and Gendersee footnote21



Race and Ethnicity

In 2000, the rate of opioid-related fatal overdose was 5.8 per 100,000 people in Massachusetts, according to DPH data. That rate has increased steadily since then, with the figure hitting 11.1 per 100,000 in 2012. However, the increase in the last three years has been especially sharp. By 2015, there were 23.3 fatal overdoses for every 100,000 residents.

While the death rate within Massachusetts differs for various racial and ethnic groups, people from all backgrounds in the Bay State are caught up in the deadly epidemic. In the adjoining graph, we can see the overdose rates of three of the state’s largest groups for the last two years. By comparison, the national average was 9.7 per 100,000 in 2014. As seen in the graph, the age-adjusted, normalized data reveals that the epidemic is hitting the White non-Hispanic population at a rate around twice that of Black non-Hispanic population for the last two years, and roughly 50% more than the rate for the Hispanic population over that time.

Interpreting Data

Using age-adjusted data is important because different groups have different age distributions, whether those groups are broken out by racial/ethnic, gender, or geographic lines. For example, the Hispanic population in Massachusetts is relatively younger than other racial/ethnic groups in the state. Without taking age distribution into account, the fact that younger people are more likely to die from opioid-related overdoses could result in an over-estimated death rate for the Hispanic community as a whole. We might experience similar mischaracterization when looking at cities and towns that skew older or younger than the rest of the state. In these ways and others, age-adjusting population data helps public health officials get a more accurate picture of the crisis and better target the most problematic areas and populations.

Statisticians use confidence intervals to indicate the level of certainty of a measurement by showing a range of likely results. Analyzing a population is often done by looking at samples that are intended to be representative of the whole group. It is easier to assess whether that representation is accurate when the sample size is larger. For example, it is easier to trust the results of a survey with thousands of respondents than a survey with only a dozen respondents. So, adjusted for different sample sizes, confidence intervals show the precision of different results.

When counts are smaller, rates are less precise and confidence intervals are wider. Larger samples have narrower ranges. Note that the confidence intervals on the rates for the Black non-Hispanic category are much wider than those around the rates for the White non-Hispanic category. This is because fewer non-Hispanic Blacks are dying from opioid-related overdoses than non-Hispanic Whites, so their sample size is smaller.

When comparing two results, you can only be sure that there is truly a difference when the confidence intervals do not overlap. An example of this is seen in the death rates for the Black non-Hispanic and Hispanic populations. While the projections look higher for 2015, since the confidence intervals overlap, we can’t be sure that the numbers are significantly different from 2014 because the results could fall anywhere within either overlapping range.

When doing population analysis, statisticians will often use a rate per sample size (example: rate per 100,000), rather than just a raw count. Densely populated areas are more likely to show many types of behavior, whether good or bad, because there are simply more people. Using raw count, the largest cities would always show up as hot spots and probably draw the most focus and resources. By contrast, a raw count change from 100 to 200 in a city of 1 million (was 0.01%, now 0.02%) might not seem as significant as the same change in a town of 2,000 (was 5%, now 10%).

For example, since the White non-Hispanic population is larger in Massachusetts than other similar groups, if we just went by raw count, we couldn’t be sure whether the higher number of opioid-related deaths reflected a larger problem, or just a larger sample. By normalizing all the rates to the same sample size, we can properly compare groups to see that the problem is truly more prevalent among non-Hispanic Whites than among other groups.

Comparing apples to apples by standardizing to a normalized rate helps public health officials get a more accurate picture so they can develop the right strategies to combat the epidemic.

Incarcerated Population

When an inmate is released from prison in Massachusetts, their ability to re-enter society is being threatened by the opioid crisis. The risk of opioid-related death following release from incarceration is more than 50 times greater than for the general public. What’s more concerning is that the threat is immediate. Fatal overdoses during the first month after release are six times higher than for all other post-incarceration periods.

Among inmates who both were released and died between 2013 and 2014, opioid-related overdose was the cause of death for 40% of these people. Following the age trend noted above, the risk of death for people aged 18–24 in this group is roughly 10 times higher than for individuals 45 or older. While some inmates receive substance use treatment while incarcerated, the data from this study does not include how, when, or for how long that treatment takes place.

The Future

The opioid epidemic won’t be solved overnight, and there’s no easy solution to make this problem disappear. However, there are signs of hope and a turning tide.

The state has recently taken a number of important steps to address the crisis. From campaigns aimed at shifting the culture around how the public views addiction, to giving our health care professionals the tools they need to responsibly prescribe opioids and monitor prescriptions, Massachusetts is working to end the epidemic.

While there is still a lot to do, findings from the Chapter 55 report have helped elected officials and public health leaders determine what should be done next.

Footnotes

  1. The confirmed opioid-related death rate was suppressed in towns that were detected as strong outliers using Tukey’s outlier filter. All values that fell outside of the upperbound, calculated using three times the interquartile range, were considered strong outliers. Rates for Provincetown, Cummington, and Granville were suppressed from 2001 to 2005. Rates for Aquinnah, New Ashford, and Tyringham were suppressed from 2011 to 2015.
  2. In both 2014 and 2015, there was one death of a Massachusetts resident whose city/town of residence was not known.
  3. Please note that data for 2000-2013 have been updated following a review of cases that did not receive an official cause of death at the time the file was closed. Death data for 2014-2015 are preliminary and subject to updates. Case reviews of deaths are evaluated and updated on an ongoing basis. A large number of death certificates have yet to be assigned final cause-of-death codes. These counts are based on the estimates rather than confirmed cases.
  4. Cases were defined using the International Classification of Disease, Tenth Revision (ICD-10) codes for mortality. The following codes were selected from the underlying cause of death field to identify poisonings/overdoses: X40-X49, Y10-Y19. All multiple cause of death fields were then used to identify an opioid-related death: T40.0, T40.1, T40.2, T40.3, T40.4, and T40.6.
  5. The average annual opioid-related death rate was calculated in five-year intervals. The death rate displayed is the crude, non age-adjusted rate.
  6. In 1999, the International Classification of Diseases, Tenth Revision (ICD-10) replaced the International Classification of Diseases, Ninth Revision (ICD-9) for coding all mortality data. Because there were changes made in the codes that are assigned to causes of death, changes to the rules used to determine the underlying cause of death, and changes in the codes that comprise the leading cause of death categories, direct comparisons of causes of death between 1999 and previous years cannot be made.
  7. The Massachusetts age-adjusted opioid-related death rate was provided by the Massachusetts Department of Public Health.
  8. The national level data was extracted from the Centers for Disease Control and Prevention, National Center for Health Statistics Wonder Databases.
  9. "Opioids" includes "Heroin" and "Other Opioids". "Other Opioids" includes non-prescription Methadone, Oxycodone, non-prescription Suboxone, prescription opiates, non-prescription opiates, and other opiates.
  10. "Other" includes Crack/Cocaine, PCP, other hallucinogens, Methamphetamine, other amphetamines, other stimulants, benzodiazepines, other tranquilizers , barbiturates, other sedatives, inhalants, OTC, club drugs, and other.
  11. All out-of-state enrollments and Massachusetts County Correction Facility enrollments are excluded.
  12. Data were prepared on Sep 12, 2016 with data as of July 15, 2016.
  13. To protect client confidentiality, categories with 5 or fewer admissions are supressed.
  14. For the purposes of the study, "adults" is defined as the nearly 3.5 million residents aged 11 and older.
  15. "Prescription opioids" includes Hydrocodone, Hydromorphone, Oxycodone, Oxymorphone, Codeine, and Tramadol.
  16. "Both Fentanyl and Heroin" includes Fentanyl, Heroin, and Morphine (likely Heroin).
  17. "Legal opioid prescription" includes any prescription for Fentanyl, Methadone, Hydrocodone, Hydromorphone, Oxycodone, Oxymorphone, Morphine, or Codeine.
  18. Some individuals may see a primary care physician who then directs them to a specialist, depending on the medical issue. In some cases, both the primary physician and specialist may provide opioids to the patient for various reasons, including for immediate pain relief. Emergency room visits might also fall under this category.
  19. Some health centers or clinics could have a pool of multiple physicians who collectively treat all patients. This could result in one patient receiving multiple opioid prescriptions from different physicians on separate visits for various reasons, including for immediate pain relief.
  20. Data from the National Drug Threat Assessment Summary. Sources: 2013, 2014. Data is not available for 2012.
  21. Data from 2013-2014.