In North Carolina, the number of deaths from unintentional drug overdoses has increased
more than 300 percent in just over a decade, from 279 in 1999 to 1,140 in 2011. An
increasing proportion of these deaths come from prescription drugs as opposed to illicit
drugs. In particular, prescription opioids are involved in a majority of unintentional
drug overdose deaths.
Prescription drug overdose deaths are preventable, yet the death toll continues to
increase. This dramatic increase is a relatively new phenomenon and the regulatory
structure around prescription drugs differs in important ways from the one around
illicit drugs. With that in mind, the goal of this paper is to examine and evaluate
the current public health surveillance systems and law enforcement records with regard
to unintentional prescription drug overdoses in North Carolina. In particular, it
looks at the extent to which these systems record information about the source of
the drugs involved in the overdose. Before we can design effective interventions to
reduce unintentional overdoses, we need to know how victims obtain the drugs that
contribute to their deaths, as well as whether and where that information exists.
There are many paths through which those at risk of a fatal prescription drug overdose
may obtain the drugs that contribute to their deaths, including through legitimate
prescriptions; doctor shopping; non-legitimate prescriptions (“pill mills”); receiving,
purchasing, or stealing from family or friends; and purchasing on the street. Each
path requires a different type of intervention; therefore, determining the relative
importance of each path will guide recommendations for improving existing policies
or implementing new ones.
Several programs have already been implemented in North Carolina, each primarily addressing
one source. These include Project Lazarus (legitimate prescriptions), the North Carolina
Controlled Substances Reporting System (CSRS) (doctor shopping), the State Bureau
of Investigation’s Diversion and Environmental Crimes Unit (non-legitimate prescriptions
and purchasing on the street), and Operation Medicine Cabinet (receiving or stealing
from family or friends).
Data and Methods
Using a data set compiled by the North Carolina Division of Public Health’s Injury
and Violence Prevention Branch, I analyzed the characteristics of the unintentional
pharmaceutical-related overdose deaths in North Carolina from 2010. This data set
included information from death certificates, medical examiner files, and controlled
substance prescription records. The analysis included categorizing cases according
to the number and currency of controlled substance prescriptions as well as according
to the types of drugs contributing to death. I also looked for evidence of diversion
among the cases. This included identifying doctor shopping using three different criteria
as well as identifying other types of diversion from information available in the
medical examiner narratives. Finally, I evaluated how providers, pharmacists, and
the State Bureau of Investigation are using the North Carolina Controlled Substance
Of the 707 cases that were analyzed, unintentional prescription overdose victims were
more likely to be male, white, and/or between the ages of 35 and 54. Over half of
the cases (57 percent) had at least one current prescription for a controlled substance
at the time of death. Additionally, of those who did have at least one current prescription,
72 percent had a current prescription for a drug that also contributed to their deaths.
Opioids were by far the most common type of drug to contribute to death. Overall,
opioids contributed to 94 percent of deaths, followed by benzodiazepines at 28 percent.
In fact, all of the top ten specific drugs (e.g., oxycodone, alprazolam) to contribute
to death were either an opioid or a benzodiazepine. Opioids and benzodiazepines were
also more likely to contribute to death for those cases who had at least one current
prescription for a contributory drug than for those who did not.
The three doctor shopping criteria produced widely varying estimates, from a low of
16 cases using medical examiner narratives to a high of 252 cases using a criterion
of filling prescriptions from at least five different prescribers in one year. The
medical examiner narratives contained information about diversion sources for 78 cases,
the most common source mentioned being receiving or stealing from family or friends.
Fewer than half of the cases were looked up in the CSRS by anyone in the year before
their deaths, which may have contributed to excessive prescriptions.
Conclusions and Policy Implications
Although North Carolina currently has a system in place that is intended to ensure
that controlled substances are prescribed and used safely, unintentional overdoses
from these drugs continue to increase. Though they are not definitive, these results
provide at least preliminary evidence about where the system is failing, which can
in turn guide potential policy changes.
The following recommendations are based on my evaluation of the current public health
surveillance system and law enforcement records:
• Promote and evaluate increased use of the CSRS among prescribers and pharmacists
when prescribing or dispensing an opioid or benzodiazepine.
• Develop criteria to identify unusual or suspicious patterns of prescribing by providers.
• Develop police investigation guidelines for collecting consistent information related
to intent and to the source of the contributing drug(s).
• Create a comprehensive surveillance system to monitor and analyze prescription drug
overdose trends over time.
However, any policy to reduce overdose deaths should minimize a “chilling effect,”
which would unnecessarily restrict access to these drugs for those who have a legitimate
need for them. Additionally, a comprehensive strategy to reduce overdose deaths should
also attempt to reduce spillover from prescription drug overdoses to heroin overdoses,
as well as address the demand side of prescription drug abuse.