Original Article

Temporal Trends and Geographic Variations in Mortality Rates from Prescription Opioids: Lessons from Florida and West Virginia

Authors: Sarah A. Palumbo, BS, Charles H. Hennekens, MD, DrPH, Janet D. Robishaw, PhD, Robert S. Levine, MD


Objectives: To explore temporal trends and geographic variations in mortality from prescription opioids from 1999 to 2016.

Methods: Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research Multiple Cause of Death files were used to calculate age-adjusted rates and 95% confidence intervals (CIs) and create spatial cluster maps.

Results: From 1999 to 2016, counties in West Virginia experienced the highest overall mortality rates in the United States from prescription opioids. Specifically, from 1999 to 2004, the highest rate in West Virginia of 24.87/100,000 (95% CI 17.84–33.73) was the fourth highest in the United States. From 2005 to 2009, West Virginia experienced the highest rate in the United States, 60.72/100,000 (95% CI 47.33–76.71). From 2010 to 2016, West Virginia also experienced the highest rate in the United States, which was 90.24/100,000 (95% CI 73.11–107.36). As such, overall, West Virginia experienced the highest rates in the United States and the largest increases overall of ~3.6-fold between 1999 and 2004 and 2010 and 2016. From 1999 to 2004, Florida had no “hot spots,” but from 2006 to 2010 they did appear, and from 2011 to 2016, they disappeared.

Conclusions: These data show markedly divergent temporal trends and geographic variations in mortality rates from prescription opioids, especially in the southern United States. Specifically, although initial rates were high and continued to increase alarmingly in West Virginia, they increased but then decreased in Florida. These descriptive data generate hypotheses requiring testing in analytic epidemiological studies. Understanding the divergent patterns of prescription opioid-related deaths, especially in West Virginia and Florida, may have important clinical and policy implications.
Posted in: Public Health & Environmental Medicine3

This content is limited to qualifying members.

Existing members, please login first.

If you have an existing account please login now to access this article or view your purchase options.

Purchase only this article ($15)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.


1. Rudd RA, Seth P, David F, et al. Increases in drug and opioid-involved overdose deaths-United States, 2010-2015. MMWR Morb Mortal Wkly Rep 2016;65:1445-1452.
2. Tompkins DA, Hobelmann JG, Compton P. Providing chronic pain management in the "fifth vital sign" era: historical and treatment perspectives on a modern-day medical dilemma. Drug Alcohol Depend 2017;173:S11-S21.
3. Baker DW. History of The Joint Commission’s pain standards. Lesson’s for today’s prescription opioid epidemic. JAMA 2017;317:1117-1118.
4. Lohman D, Schleifer R, Amon JJ. Access to pain treatment as a human right. BMC Med 2010;8: 8 (2010).
5. Porter J, Jick H. Addiction rare in patients treated with narcotics. N Engl J Med 1980;302:123.
6. Van Zee A. The promotion and marketing of OxyContin: commercial triumph, public health tragedy. Am J Public Health 2009;99:221-227.
7. Guy GP, Zhang K, Bohm MK, et al. Vital signs: changes in opioid prescribing in the United States, 2006-2015. MMWR Morb Mortal Wkly Rep 2017;66:697-704.
8. Kandel DB, Hu M-C, Griesler P, et al. Increases from 2002 to 2015 in prescription opioid overdose deaths in combination with other substances. Drug Alcohol Depend 2017;178:501-511.
9. Colon-Berezin C, Nolan ML, Blachman-Forshay J, et al. Overdose deaths involving fentanyl and fentanyl analogs-New York City, 2000-2017. MMWR Morb Mortal Wkly Rep 2019;68:37-40.
10. US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics (NCHS). Multiple Cause of Death file: 1999-2017. https://wonder.cdc.gov/mcd.html. Accessed November 3, 2018.
11. Centers for Disease Control and Prevention. Mortality data from the National Vital Statistics System. MMWR Morb Mortal Wkly Rep 1989;38:119-123.
12. Centers for Disease Control and Prevention. U.S. standard certificate of death. https://www.cdc.gov/nchs/data/dvs/DEATH11-03final-acc.pdf. Accessed January 6, 2020.
13. USAGov. Issues with family outside the U.S. https://www.usa.gov/family-outside-us. Accessed June 4, 2019.
14. Anderson RN, Rosenberg HM. Age standardization of death rates: implementation of the year 2000 standard. Natl Vital Stat Rep 1998;47:1-16.
15. Seth P, Rudd RA, Noonan RK, et al. Quantifying the epidemic of prescription opioid overdose deaths. Am J Public Health 2018;108:500-502.
16. Esri. Optimized hot spot analysis. ArcMap. http://desktop.arcgis.com/en/arcmap/10.3/tools/spatial-statistics-toolbox/optimized-hot-spot-analysis.htm. Accessed December 1, 2018.
17. Kennedy-Hendricks A, Richey M, McGinty EE, et al. Opioid overdose deaths and Florida’ crackdown on pill mills. Am J Public Health 2016;106:291-297.
18. Rutkow L, Chang H-Y, Daubresse M, et al. Effect of Florida’ prescription drug monitoring program and pill mill laws on opioid prescribing and use. JAMA Intern Med 2015;175:1642.
19. Johnson H, Paulozzi L, Porucznik C, et al. Decline in drug overdose deaths after state policy changes-Florida, 2010-2012. MMWR Morb Mortal Wkly Rep 2014;63:569-574.
20. National Institute on Drug Abuse. Florida: opioid summaries by state. https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state/florida-opioid-summary. Revised May 2019. Accessed January 6, 2020.
21. Pitt AL, Humphreys K, Brandeau ML. Modeling health benefits and harms of public policy responses to the US opioid epidemic. Am J Public Health 2018;108:1394-1400.
22. Florida Senate, Health and Human Services Committee, Health Quality Subcommittee, et al. CS/CS/HB 249: Drug Overdoses 2017. https://www.flsenate.gov/Session/Bill/2017/0249. Accessed March 3, 2019.
23. Florida Senate, Health and Human Services Committee, Health Quality Subcommittee, et al. CS/CS/HB 21: Controlled Substances 2018. https://www.flsenate.gov/Session/Bill/2018/21. Accessed March 3, 2019.
24. Sykes A, Derby D, Faught G, et al. Compliance and best practice for an act regulating the use of opioid drugs. Oklahoma Senate Bills 1446 & 848. Accessed January 10, 2019.
25. Martz MP, Ruberto I, Ampadu L, et al. 50 state review on opioid related policy. https://www.azdhs.gov/documents/prevention/womens-childrens-health/injury-prevention/opioid-prevention/50-state-review-printer-friendly.pdf. Published 2017. Accessed December 9, 2018.
26. Area Health Resources Files. Nurse practitioners. https://data.hrsa.gov/topics/health-workforce/ahrf. Accessed October 7, 2019.
27. Fink PB, Deyo RA, Hallvik SE, et al. Opioid prescribing patterns and patient outcomes by prescriber type in the Oregon Prescription Drug Monitoring Program. Pain Med 2018;19:2481-2486.
28. Robishaw J, Caceres J, Hennekens CH. Genomics and precision medicine to combat opioid use disorder. Am J Med 2019;132:395-396.