A Lack of Specificity in Drug Identification on Death Certificates

As previously noted in the article "How CDC Misled the Nation Using Distorted Data," only 8.5% of all deceased individuals in the United States undergo an autopsy. Furthermore, “medical examiner and coroner offices are overwhelmed, leading to minimal toxicology testing and often no autopsies, contrary to established standards.”

The authors of the commentary further explored how inaccuracies in overdose data arose, pointing to weaknesses in the International Classification of Diseases (ICD-10) tracking codes relevant to overdoses.

“Until 2016, the National Vital Statistics System (NVSS) calculated annual deaths involving prescription opioids by summing deaths identified by ICD codes T40.2, T40.3, and T40.4. In 2016, these codes accounted for 32,445 deaths. Code T40.4 was identified as the source of the error noted by CDC analysts. This systemic error likely began between 2005 and 2007, when the CDC and the Drug Enforcement Administration (DEA) recorded 1,013 deaths attributed to illicitly manufactured fentanyl (IMF) mixed with heroin in certain midwestern and northeastern states.”

Despite being informed of IMF's presence since the earlier outbreak, the NVSS continued to categorize all death certificates mentioning fentanyl as a prescribed drug, a critical oversight with significant implications for public policy and health.

Thus, the CDC has possibly been compounding this error since 2005. The assumption that patients prescribed pain relief medications are a major factor in the crisis is based solely on a flawed ICD-10 code, unsupported by clear evidence. A fundamental principle of science is that correlation does not imply causation, yet the ongoing lack of drug specificity in both ICD-10 codes and death certificates has allowed this unfounded assumption to persist in discussions and research regarding this vulnerable demographic.

While this information might not be new to experts, it is indeed explosive. There remains only an assumption that patients like the elderly, individuals with autoimmune diseases, or those suffering from cancer are significantly overdosing on prescribed medications. This correlation drawn by the CDC exemplifies the "questionable cause" fallacy: "A is regularly associated with B, therefore, A causes B." In layman's terms, “people are dying from opioid overdoses, opioids are often prescribed to patients in pain, hence patients must be overdosing on opioids.” This conflation has not deterred several federal agencies from expending billions in taxpayer dollars to restrict legal access to pain relief medications.

The prevailing narrative suggests that to “protect” people from overdosing on prescribed medications, even those with terminal conditions, access to medical supplies must be further limited. However, it remains unclear whether patients are genuinely contributing to the crisis or if a different demographic (e.g., casual drug users) is responsible. Recent observations seem to support the latter view.

Licit vs. Illicit Drugs and Medical Tracking Codes

After identifying inaccuracies in the 2016 statistics regarding “prescription opioid” overdose deaths, CDC analysts recalibrated the figures using a more conservative approach that excluded all deaths recorded under the T40.4 ICD-10 code—the source of the initial error. This adjustment resulted in a staggering 47.3% reduction in the estimated number of deaths attributed to “prescription opioids,” yet it still fails to account for prescription overdose deaths linked to illicitly acquired medications. Consequently, the CDC remains uncertain regarding how the remaining 17,087 decedents accessed these drugs, likely deriving from leftover prescriptions found in personal medicine cabinets.

Given that the CDC cannot differentiate between overdoses among casual users and those involving patients prescribed analgesics, it is currently impossible to ascertain how many of these deaths pertain to patients. The absence of robust demographic data is troubling, particularly as this information impacts the lives of millions of Americans. Nevertheless, many studies indicate that patients rarely misuse, abuse, or overdose on their medications, suggesting they are not the primary drivers of the crisis.

In October 2018, Congress recognized this issue when the Support for Patients and Communities Act was enacted, mandating the CDC to modernize its coding for drug overdose-related deaths. Yet, the CDC has yet to undertake this modernization, and it appears no significant progress has been made. The commentary also highlighted additional concerns regarding the coding of benzodiazepines and non-opioid drugs like cocaine, indicating that the lack of drug specificity diminishes the value of surveillance data for substances typically linked to fatalities.

Moreover, the authors raised serious concerns regarding methadone. The CDC has struggled to distinguish between methadone prescribed for pain and that administered at Narcotic Treatment Facilities. Yet, in 2017, a CDC report claimed that “the majority of methadone-associated morbidity and mortality likely arises from its use for pain,” without providing supporting evidence. Instead, U.S. data on methadone distribution to retail pharmacies for pain management versus distribution to opioid treatment programs indicated an inverse relationship in usage across both demographics.

The authors concluded this section by asserting that the reliability of ICD-10 codes in accurately reflecting mortality data for “prescribed” opioids is questionable, necessitating scrutiny of how the CDC codes methadone-related deaths.

Other Errors: Up to 30% of Death Certificates Are Incorrect

The commentary further revealed that most preliminary death certificates are issued before toxicology results are available, and between 20% and 30% of death certificates submitted to the CDC contain inaccuracies. This issue is distinct from how the CDC codes drug-related deaths. While the CDC recommends submitting supplemental death certificates once toxicology results are finalized, the authors acknowledged that this guidance is often overlooked. Generally, the agency compiles national vital statistics without verifying the accuracy of the data it receives.

A report from USA Today cited the percentage of incorrect death certificates noted by the authors, stating, “A review of Missouri hospitals in 2017 found that nearly half of death certificates contained erroneous causes of death. A Vermont study revealed that 51% of death certificates had significant errors. Additionally, nearly half of the physicians surveyed by the CDC in 2010 admitted to knowingly reporting inaccurate causes of death.”

This means that the CDC begins its mortality data compilation with unverified source data that can be erroneous up to 30% of the time. Moreover, data may originate from preliminary certificates that are not consistently updated following toxicology testing, compounding the inaccuracies.

CDC Misses Critical Health Signals

Another major issue highlighted in the commentary is polysubstance misuse. The presence of multiple drugs complicates the postmortem identification of causes of death. In many cases where toxicology screenings were conducted, an average of six substances were detected at the time of death. The commentary emphasized that polysubstance overdoses constitute a majority of overdose fatalities, yet this critical fact often goes unrecorded on death certificates due to legal requirements mandating a single cause of death.

The stated goal of health surveillance, according to federal agencies, is to quickly identify emerging health threats. Bureaucrats often prioritize public health over individual privacy rights, justified by an ethical framework that differs from those governing clinical and bioethics. The expectation is that this trade-off will enable rapid detection and mitigation of public health threats.

Many Americans would be astonished by the extent of private health data collected. However, repeated alerts regarding deficiencies in the CDC’s data compilation and analysis practices have been disregarded, resulting in missed signals regarding significant public health threats, notably IMF. Public health agencies claim their mission is to safeguard public health, which supposedly warrants extensive surveillance activities, yet they have overlooked vital signals for over a decade. This raises ethical concerns about the system's failure to function effectively, leaving Americans burdened with the consequences of a flawed system.

Despite being aware of the lack of drug specificity since 2005, the CDC has perpetuated the narrative that pain patients are responsible for driving overdose statistics through a public relations campaign and the controversial 2016 guidelines. Consequently, many stable patients were abruptly tapered off their medications by fearful physicians, concerned about losing their licenses amid increasing litigation and negative media portrayals of doctors as contributors to the crisis.

Overdose Rates Continue to Rise Despite Federal Interventions

The U.S. recorded a historical high in unintentional overdoses, despite extensive governmental efforts. Significant taxpayer funds have been allocated to limit patient access to analgesics and promote alternatives lacking substantial evidence, while little attention has been directed toward IMF.

As previously discussed, “less than 1% of chronic pain patients without a history of substance abuse become addicted to opioids during treatment.” This statistic has been corroborated by various studies, indicating that pain patients are unlikely to play a meaningful role in the overdose crisis.

The persistent question remains: why are mitigation efforts primarily focused on public health interventions that further restrict patient access to medications? A considerable amount of evidence suggests that patients suffering from chronic pain have become a convenient political externality, and their suffering has turned profitable, resulting in a healthcare environment characterized by increased social control.

This situation arises from the narrative and moral panic surrounding opioids, fueled by flawed data. The systemic failure to parse and correctly interpret data has been evident to the CDC for some time.

Many patients have lost access to legal medications, which have not been proven “ineffective” or “unsafe” under the care of licensed professionals. This series of events has unfolded in the cultural and policy landscape due to a misguided assumption that has been reiterated endlessly without scientific validity.

When considering all scientific observations in totality, the notion of a “prescription drug overdose crisis” collapses under scrutiny. Yet, patients continue to suffer, while those seeking help for substance use disorders find themselves at increased risk of overdose or death due to the prevalence of IMF in the streets and the persistent stigmatization of individuals with such disorders. The prevailing narrative and policy environment continue to dismiss a wealth of empirical evidence supporting the safety and efficacy of opioid analgesics for legitimate medical use, whether for acute or chronic pain not associated with cancer.

Summation

1. Only about 8% of deceased individuals in the U.S. receive an autopsy, and minimal toxicology testing is standard practice during the overdose crisis.
2. ICD-10 tracking codes do not distinguish between legally acquired medications and illicit substances, applicable to opioids, benzodiazepines, cocaine, and methadone.
3. The so-called “prescription drug overdose crisis” is, in fact, an illicit fentanyl and polypharmacy crisis, a view that many experts have held for years, and only recently has the discussion started to shift in light of scientific findings that challenge the mainstream narrative.
4. The assertion that pain patients significantly contribute to the crisis was always an unfounded assumption lacking the necessary evidence to establish a correlation. Ignoring those harmed by this easily debunked hypothesis reflects systemic corruption rather than individual wrongdoing.
5. Pain patients continue to endure unnecessary suffering based on an assumption that some believe should be perpetuated. Innocent individuals now struggle to obtain essential primary care due to stigmatizing narratives pushed by those prioritizing profit.
6. The CDC, federal agencies, states, and the media collectively contribute to the stigmatization of severely ill patients, often without direct evidence.
7. Up to 30% of death certificates analyzed by the CDC are inaccurate, and the agency accepts almost all data without scrutiny except in rare instances. Preliminary certificates are frequently not updated with toxicology results, resulting in a reliance on assumptions rather than scientific accuracy.
8. Due to the CDC’s incompetence, significant public health signals, such as the rise of IMF, have gone unnoticed, while efforts to stigmatize and limit legal access to analgesics for patients with severe pain continue, based on an exaggerated fear of addiction and overdose, despite the demonstrated low risk in this demographic.
9. The vulnerabilities within the current ICD-10 codes for overdose deaths remain unaddressed, and the public has received no timeline for expected improvements to ensure better outcomes for American taxpayers and to focus attention on IMF-related overdoses.
10. For over a decade, the CDC’s flawed reports have gone unchallenged, serving as the foundation for public policy decisions made by Congress and the Executive Branch, with media coverage seldom questioning or verifying the information provided.
11. From 2012 to 2020, the federal government allocated $261.3 billion for drug control, with states likely spending a comparable amount.
12. Despite these vast expenditures and public health initiatives, 2020 marked a record year for overdose fatalities.
13. Many Americans were misled into believing that “opiate overdoses, once almost entirely due to heroin use, are now increasingly linked to prescription painkillers.” They remained unaware that the CDC’s categorization of prescription painkillers included illicitly manufactured fentanyl and non-prescribed methadone dispensed to individuals undergoing treatment for opioid use disorder.
14. The CDC lacks a reliable method to determine the annual number of prescription opioid overdose deaths.

Conclusion

This raises a critical question: what will it take for the extensive apparatus dedicated to a failing drug war, now waged against its own ailing citizens, to produce rational policies and accurate data? Public health agencies failed to track patient outcomes following their heavy-handed interventions targeting a demographic that was only ever assumed to be a factor in the crisis. The so-called “science” backing this approach resembles a logical fallacy known as an appeal to possibility: “X is possible, therefore, X is true.” This lack of convincing evidence is deemed acceptable by the CDC.

This review is explosive, with far-reaching implications that are unacceptable for an agency that has utilized $261.3 billion in taxpayer funds and engaged in a public relations campaign to improve its image following an extremely unpopular and scientifically unfounded guideline affecting millions of patients.

After all this investment and effort, instead of witnessing a reduction in overdose fatalities, the U.S. experienced several thousand additional deaths in 2020. These figures represent real lives lost due to a public health agency failing to recognize signals it was responsible for monitoring. The CDC overlooked the threat posed by IMF while justifying its aggressive approach to medical practice, straying dangerously from its intended purpose.

Federal agencies operate with minimal accountability, and it is time for our institutions and watchdogs to address this issue.