Analyzing the drug abuse epidemic There is a developing drug epidemic in the United States. Jalal et al. analyzed nearly 600,000 unintentional drug overdoses over a 38-year period. Although the overall mortality rate closely followed an exponential growth curve, the pattern itself is a composite of several underlying subepidemics of different drugs. Geographic hotspots have developed over time, as well as drug-specific demographic differences. Science, this issue p. eaau1184 The drug overdose epidemic in the United States is a composite of drug-specific subepidemics. INTRODUCTION The epidemic of substance use disorders and drug overdose deaths is a growing public health crisis in the United States. Every day, 174 people die from drug overdoses. Currently, opioids (including prescription opioids, heroin, and synthetic opioids such as fentanyl and its chemical analogs) are the leading cause of overdose deaths. The overdose mortality data can reveal the complex and evolving dynamics of drug use in the United States. RATIONALE Reports on the U.S. drug overdose epidemic tend to focus on changes in yearly statistics. Improved understanding of the long-term dynamics of the overdose epidemic may aid in the development of more effective epidemic prevention and control strategies. At present, there are no reliable methods to forecast the likely future course of the epidemic. We focused on deaths from overdoses as a relatively reliable metric of the epidemic because all deaths are required to be reported in all U.S. states and territories using the standardized International Classification of Diseases. In an effort to understand the epidemic dynamics and perhaps predict its future course, we analyzed records of 599,255 deaths from 1979 through 2016 from the National Vital Statistics System where unintentional drug poisoning was identified as the main cause of death. We examined the time course of the overall number of deaths; the contributions of individual drugs (prescription opioids, heroin, synthetic opioids like fentanyl, methadone, cocaine, methamphetamine) to the overall curve; changes in the populations most affected by each drug as measured by demographic factors of age, sex, race, and urbanicity; and changes in the geographic distribution of deaths due to each drug as measured by the county of residence of each decedent. RESULTS The overall mortality rate for unintentional drug poisonings in the United States grew exponentially from 1979 through 2016. This exponentially increasing mortality rate has tracked along a remarkably smooth trajectory (log linear R2 = 0.99) for at least 38 years (left panel). By contrast, the trajectories of mortality rates from individual drugs have not tracked along exponential trajectories. Cocaine was a leading cause in 2005–2006, which was overtaken successively by prescription opioids, then heroin, and then synthetic opioids such as fentanyl. The demographic patterns of deaths due to each drug have also shown substantial variability over time. Until 2010, most deaths were in 40- to 50-year-old persons, from cocaine and increasingly from prescription drugs. Deaths from heroin and then fentanyl have subsequently predominated, affecting younger persons, ages 20 to 40 (middle panel). Mortality rates for males have exceeded those for females for all drugs. Rates for whites exceeded those for blacks for all opioids, but rates were much greater among blacks for cocaine. Death rates for prescription drugs were greater for rural than urban populations. The geographic patterns of deaths also vary by drug. Prescription opioid deaths are widespread across the United States (right panel), whereas heroin and fentanyl deaths are predominantly located in the northeastern United States and methamphetamine deaths in the southwestern United States. Cocaine deaths tend to be associated with urban centers. The online manuscript provides many details of the patterns of mortality in these data. CONCLUSION The U.S. drug overdose epidemic has been inexorably tracking along an exponential growth curve since at least 1979. Although there have been transient periods of minor acceleration or deceleration, the overall drug overdose mortality rate has regularly returned to the exponential growth curve. This historical pattern of predictable growth for at least 38 years suggests that the current opioid epidemic may be a more recent manifestation of an ongoing longer-term process. This process may continue along this path for several more years into the future. Paradoxically, there has been substantial variability with which specific drugs have become dominant in varying populations and geographic locales. This variability all but negates the possibility of confident predictions about the future role of specific drugs. Indeed, it is possible that a future overdose epidemic may be driven by a new or obscure drug that is not among the leading causes of drug overdose death today. Understanding the forces that are holding multiple subepidemics together onto a smooth exponential trajectory may be important in revealing, and effectively dealing with, the root causes of the epidemic. Exponential growth in overdose deaths. The smooth overall U.S. overdose mortality curve (left panel) is a composite of multiple subepidemics, as revealed by changing patterns of overdose deaths by age distribution (middle panel; color indicates deaths per 100,000 persons), and by geography (right panel; color shows hotspots), for prescription opioids (upper) and heroin (lower). Subepidemic patterns for other drugs are shown in the full manuscript. Better understanding of the dynamics of the current U.S. overdose epidemic may aid in the development of more effective prevention and control strategies. We analyzed records of 599,255 deaths from 1979 through 2016 from the National Vital Statistics System in which accidental drug poisoning was identified as the main cause of death. By examining all available data on accidental poisoning deaths back to 1979 and showing that the overall 38-year curve is exponential, we provide evidence that the current wave of opioid overdose deaths (due to prescription opioids, heroin, and fentanyl) may just be the latest manifestation of a more fundamental longer-term process. The 38+ year smooth exponential curve of total U.S. annual accidental drug poisoning deaths is a composite of multiple distinctive subepidemics of different drugs (primarily prescription opioids, heroin, methadone, synthetic opioids, cocaine, and methamphetamine), each with its own specific demographic and geographic characteristics.

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1979 年至 2016 年美国药物过量流行的动态变化

分析药物滥用流行病 在美国有一种正在发展的药物流行病。贾拉尔等人。分析了 38 年间近 600,000 次无意药物过量。尽管总体死亡率密切遵循指数增长曲线，但该模式本身是不同药物的几种潜在亚流行病的复合体。随着时间的推移，地理热点以及特定于药物的人口差异已经形成。科学，这个问题 p。eaau1184 美国的药物过量流行是特定药物亚流行的复合体。简介 物质使用障碍和药物过量死亡的流行是美国日益严重的公共卫生危机。每天有 174 人死于药物过量。目前，阿片类药物（包括处方阿片类药物、海洛因、和合成阿片类药物，如芬太尼及其化学类似物）是过量死亡的主要原因。过量死亡率数据可以揭示美国吸毒的复杂和不断发展的动态。基本原理 关于美国药物过量流行的报告往往侧重于年度统计数据的变化。更好地了解过量流行的长期动态可能有助于制定更有效的流行预防和控制策略。目前，没有可靠的方法来预测未来可能的流行病程。我们将过量用药导致的死亡作为衡量流行病的一个相对可靠的指标，因为美国所有州和地区都要求使用标准化的国际疾病分类报告所有死亡。为了了解流行动态并可能预测其未来进程，我们分析了 1979 年至 2016 年来自国家生命统计系统的 599,255 例死亡记录，其中无意药物中毒被确定为主要死因。我们检查了总死亡人数的时间过程；个别药物（处方阿片类药物、海洛因、芬太尼、美沙酮、可卡因、甲基苯丙胺等合成阿片类药物）对整体曲线的贡献；根据年龄、性别、种族和城市人口等人口统计因素衡量，受每种药物影响最大的人群的变化；每种药物导致的死亡地理分布的变化，以每个死者的居住县衡量。结果 从 1979 年到 2016 年，美国意外药物中毒的总体死亡率呈指数增长。这种呈指数增长的死亡率沿着非常平稳的轨迹（对数线性 R2 = 0.99）追踪了至少 38 年（左图）。相比之下，单个药物的死亡率轨迹并未沿着指数轨迹追踪。可卡因是 2005 年至 2006 年的主要原因，其次是处方阿片类药物，然后是海洛因，然后是芬太尼等合成阿片类药物。随着时间的推移，每种药物导致的死亡人口统计模式也显示出很大的变异性。直到 2010 年，大多数死亡发生在 40 至 50 岁的人群中，原因是可卡因和越来越多的处方药。海洛因和芬太尼导致的死亡随后占主导地位，影响 20 至 40 岁的年轻人（中图）。所有药物的男性死亡率都超过了女性。对于所有阿片类药物，白人的比率都超过了黑人，但黑人的可卡因比率要高得多。农村人口的处方药死亡率高于城市人口。死亡的地理模式也因药物而异。处方阿片类药物死亡在美国很普遍（右图），而海洛因和芬太尼死亡主要发生在美国东北部，甲基苯丙胺死亡主要发生在美国西南部。可卡因死亡往往与城市中心有关。在线手稿提供了这些数据中死亡率模式的许多细节。结论 美国 至少自 1979 年以来，药物过量流行一直沿着指数增长曲线无情地追踪。尽管有短暂的加速或减速时期，但总体药物过量死亡率已定期回到指数增长曲线。这种至少 38 年可预测增长的历史模式表明，当前的阿片类药物流行可能是正在进行的长期过程的最近表现。这个过程可能会在未来几年内沿着这条道路继续下去。矛盾的是，特定药物在不同人群和地理区域中占据主导地位存在很大差异。这种可变性几乎否定了对特定药物未来作用的自信预测的可能性。确实，未来的药物过量流行可能是由一种新的或不知名的药物驱动的，而这种药物不是当今药物过量死亡的主要原因。了解将多种亚流行病一起推向平稳指数轨迹的力量对于揭示和有效处理流行病的根本原因可能很重要。过量死亡的指数增长。平滑的整体美国用药过量死亡率曲线（左图）是多种亚流行病的复合曲线，正如通过按年龄分布（中间图；颜色表示每 100,000 人的死亡人数）和地理（右图；彩色显示）改变用药过量死亡模式所揭示的那样热点），用于处方阿片类药物（上）和海洛因（下）。其他药物的亚流行模式显示在完整的手稿中。更好地了解当前美国药物过量流行的动态可能有助于制定更有效的预防和控制策略。我们分析了 1979 年至 2016 年国家生命统计系统中 599,255 例死亡的记录，其中意外药物中毒被确定为主要死因。通过检查所有可追溯到 1979 年的意外中毒死亡数据并显示 38 年的整体曲线呈指数增长，我们提供了证据表明当前的阿片类药物过量死亡浪潮（由于处方阿片类药物、海洛因和芬太尼）可能只是更基本的长期过程的最新表现。美国总量 38+ 年平滑指数曲线