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Occupational Patterns in Unintentional and Undetermined Drug-Involved and Opioid-Involved Overdose Deaths--United States, 2007-2012.

The opioid epidemic affects multiple segments of the U.S. population (1). Occupational patterns might be critical to understanding the epidemic. Opioids are often prescribed for specific types of work-related injuries, which vary by occupation* (2). CDC used mortality data from the National Occupational Mortality Surveillance (NOMS) system to examine unintentional or undetermined drug overdose mortality within 26 occupation groups. This study included data from the 21 U.S. states participating in NOMS during 2007-2012. ([dagger]) Drug overdose mortality was compared with total mortality using proportional mortality ratios (PMRs) indirectly standardized for age, sex, race, year, and state. Mortality patterns specific to opioid-related overdose deaths were also assessed. Construction occupations had the highest PMRs for drug overdose deaths and for both heroin-related and prescription opioid-related overdose deaths. The occupation groups with the highest PMRs from methadone, natural and semisynthetic opioids, and synthetic opioids other than methadone were construction, extraction (e.g., mining, oil and gas extraction), and health care practitioners. The workplace is an integral part of life for the majority of the adult U.S. population; incorporating workplace research and interventions likely will benefit the opioid epidemic response.

NOMS is a population-based surveillance system and a collaborative effort between state vital statistics offices and CDC's National Institute for Occupational Safety and Health (NIOSH) and National Center for Health Statistics (NCHS). Through data sharing agreements with NIOSH, all participating states, or NCHS under states' direction, share selected data from their death certificates, including the decedent's usual industry and occupation, coded to the U.S. Census industry and occupation codes. This analysis includes 4,024,086 deaths that occurred in persons aged [greater than or equal to] 18 years, from the 21 states that contributed [greater than or equal to] 1 year of data * to NOMS during 2007-2012. ([section]) International Classification of Disease, Tenth Revision (ICD-10) codes for underlying cause of death were used to identify unintentional (X40-X44) and undetermined (Y10-Y14) drug overdose deaths. Among drug overdose deaths, the specific type of opioid was indicated by the following ICD-10 multiple cause of deaths codes: T40.1 (heroin) and T40.2-T40.4 (prescription opioids [i.e., T40.2, natural and semisynthetic opioids; T40.3, methadone; and T40.4, synthetic opioids other than methadone]). ([paragraph]) Deaths that involved multiple opioid types were included in multiple categories.

Usual occupation, recorded as free-text on the death certificate, was coded to 1990 or 2000 U.S. Census occupation codes ** by NIOSH or by the state. A crosswalk based on U.S. Census data was used to convert the 1990 U.S. Census occupation codes to the 2000 U.S. Census occupation codes. ([dagger][dagger]) Occupation codes were binned into 26 groups based on job duties. ([section][section]) For each outcome, the proportion of deaths among each occupation group was compared with the proportion of deaths among all occupations combined using PMRs indirectly standardized by age, sex, race, calendar year, and state of occurrence. A PMR >1.00 indicated that the proportion of deaths within that occupation group is higher than the proportion of deaths among all occupation groups combined. Corresponding 95% confidence intervals were calculated.

The analysis identified 57,810 drug overdose deaths within the study population (1.4% of the 4,024,086 deaths). The majority of drug overdose deaths were among persons who were male (61.8%), white (89.8%), and aged 45-54 years (30.1%) or 35-44 years (24.1%). ([paragraph][paragraph]) PMRs from drug overdose were significantly above 1.00 for the following six occupation groups: 1) construction (1.25); 2) extraction (1.16); 3) food preparation and serving (1.11); 4) health care practitioners and technical (1.16); 5) health care support (1.18); and 6) personal care and service (1.10) (Table 1). PMRs from drug overdose were also significantly elevated among deaths where the usual occupation was unpaid/unemployed (1.10) *** or unknown (1.31). ([dagger][dagger][dagger]) For each specific opioid type, significantly elevated PMRs were generally observed only for those occupation groups that also had a significantly elevated PMR for drug overdose overall (Table 1) (Table 2). The only two exceptions were the arts, design, entertainment, sports, and media occupation group and the building and grounds cleaning and maintenance occupation group. For these groups, the proportion of drug overdose deaths among the two occupation groups was similar to the proportion of drug overdose deaths overall (i.e., PMR approximately = 1.00), whereas the proportional distribution of specific drugs involved in an overdose was different,[section][section][section] with heroin-involved overdose deaths higher than expected (Table 1). The highest PMRs for methadone, natural and semisynthetic opioids, and synthetic opioids were in the construction (1.34), extraction (1.39), and healthcare practitioner (1.81) occupation groups, respectively.

Because the PMRs for all opioid types within the construction occupation group were elevated, a subanalysis further examined opioid-related deaths in this group. The analysis identified 7,402 drug overdose deaths among persons aged [greater than or equal to] 18 years within the construction occupation group. The majority of decedents were male (96.7%), white (92.6%), and aged 45-54 years (30.4%) or 35-44 years (26.9%). ([paragraph][paragraph][paragraph])

These deaths were examined by the following occupation subgroups ****: first-line supervisors and managers, ([dagger][dagger][dagger][dagger]) construction trade workers (e.g., carpenters, electricians, painters, iron and steel workers, operating engineers, and construction equipment operators), construction trade helpers, and other construction and related workers (e.g., building inspectors, hazardous waste workers, and highway maintenance workers). PMRs were significantly elevated for all types of opioids within the occupation subgroup construction trade workers (Table 3).

Discussion

In this study, unintentional and undetermined overdose deaths varied by occupation group, with the construction group having elevated PMRs for all drug types. Although few related studies have been conducted, similar results have been observed. In Kentucky (2011) (3) and Ohio (2016) (4), for example, overdose deaths varied by industry and occupation and were highest among construction workers. Multiyear studies conducted in two Massachusetts jurisdictions (Barnstable County and Mystic Valley Public Health Coalition communities) found trade workers (e.g., construction, building/grounds maintenance, and mechanics) had the largest proportion of opioid overdose deaths (37% and 42%, respectively) (5,6). Variation was expected because work-related injuries and illnesses vary by occupation and industry. In addition, other factors that might affect opioid use, such as psychosocial work-related stress (e.g., job insecurity or high demand/low control jobs), socioeconomic standing, and education level, also vary by occupation and industry (7-9).

The specific drugs influencing higher than expected proportions of overdose deaths also varied by occupation group. In this study, heroin PMRs were highest for the construction; food preparation and serving; and arts, design, entertainment, sports, and media occupation groups. Among the drug types evaluated, heroin is illicit, whereas among the other types, usage is both licit (i.e., prescribed and used as directed) and illicit. Data from the National Survey on Drug Use and Health illustrate that self-reported illicit drug use varies by industry. ([section][section][section][section]) The top three industries among persons aged 18-64 years who reported using illicit drugs in the past month were accommodations and food services; arts, entertainment, and recreation; and construction (10).

The variation by occupation group in this study leads to speculation about opioid initiation or use and the work environment. A single on-the-job injury (e.g., fracture or dislocation) or chronic work-related pain (e.g., caused by repetitive motion or lifting) might result in a prescription for pain medication (2,&). Workers' compensation data from 26 states (2013-2015) indicated that opioids were prescribed for 52%-80% of injured workers who received pain medications (2). Persons might also self-medicate or work in an environment with normative support for illicit drug use (9). An estimated 64.2% of self-reported illicit opioid ([paragraph][paragraph][paragraph][paragraph]) users were employed full-time or part-time in 2016. ***** As licit and illicit opioid users participate in the workforce, occupation might be an important factor in understanding and responding to the opioid epidemic.

The findings in this report are subject to at least six limitations. First, data were analyzed in aggregate, but occupational patterns for each drug type might have differed by year. Second, NOMS has limited information on the specific circumstances of death. It is not known, for example, whether the death occurred at work. Death certificates do not state whether decedents were employed at their usual job (listed on the death certificate), another job, or unemployed at the time of death; if the drug use was legal or illegal; or if drug use was initiated while decedents were employed at their usual job, another job, or before employment. Third, the specific drug involved in the drug overdose death might have been misclassified (e.g., heroin deaths misclassified as morphine deaths because of similar metabolites) or given nonspecific codes (1). Within this study, the only drug code listed for one fourth of overdose deaths was "other and unspecified drugs" (T50.9 excluding T36-T50.8). Outcome misclassification might vary by state and year. Fourth, intentional overdose deaths were excluded; however, an unknown proportion of undetermined deaths might have included homicides or suicides and might therefore have resulted in overestimates. In this study, 9.6% of drug overdose deaths were of undetermined intent. The distribution of overdose deaths by intent and occupation group need to be explored. Fifth, PMRs are mutually dependent and cannot distinguish whether occupation was associated with increasing a specific cause of death, preventing the occurrence of other causes of death, or some combination of these effects. Finally, only 21 states participated in NOMS during the study period, which limits generalizability of the findings.

This study identified occupation groups with a higher proportion of drug and opioid-specific overdose mortality but was unable to identify specific factors that might have led to the observed results. The surveillance data presented in this study generated many questions; future studies are needed to identify potential work-related factors along the causal pathway from drug initiation to overdose mortality and to investigate ways of tailoring prevention measures to specific occupations. Workplace-specific programs and policies to reduce the impact of the opioid epidemic can be implemented. Since 2009, a decline in opioid use among nonsurgical workers' compensation claims in 26 states has occurred, which is associated with changes to workers' compensation laws and regulations regarding pain management and the prescribing and distribution of opioids, in addition to corresponding national and state-level legislative and regulatory changes (2). Examples of programs ([dagger][dagger][dagger][dagger][dagger]) that might address both licit and illicit opioids include comprehensive drug-free workplace programs, employee assistance programs, peer-support networks, and education targeted to employees and employers (3,5,6). Continued evaluation of the effectiveness and impact of these programs and interventions are needed to prevent opioid misuse and abuse and to reduce opioid-related morbidity and mortality.

Summary

What is already known about this topic? A majority of the U.S. population participates in the workforce. A person's job affects both physical and psychological well-being. The opioid epidemic negatively affects workers, workplaces, and employers.

What is added by this report?

During 2007-2012 proportional mortality ratios (PMR) for heroin-related overdose deaths (1.46) and methadone-related overdose deaths (1.34) were highest for the construction occupation group. PMRs for natural and semisynthetic opioids were highest for the extraction (1.39) and health care practitioner (1.81) occupation groups.

What are the implications for public health practice?

Identification of occupations associated with drug overdose deaths further characterizes the opioid epidemic. Incorporating workplace research and targeted interventions might benefit the opioid epidemic response.

Acknowledgments

Florida Department of Health; Georgia Department of Public Health; Hawaii State Department of Health; Idaho Department of Health and Welfare; Indiana State Department of Health; Kansas Department of Health and Environment; Kentucky Department for Public Health; Louisiana Department of Health; Missouri Department of Health and Senior Services; Nebraska Department of Health and Human Services; Nevada Department of Health and Human Services; New Hampshire Department of Health and Human Services; New Jersey Department of Health; New Mexico Department of Health; North Dakota Department of Health; Ohio Department of Health; Texas Department of State Health Services; Utah Department of Health; Vermont Department of Health; Washington State Department of Health; West Virginia Department of Health and Human Resources; National Occupational Mortality Surveillance staff members, National Institute for Occupational Safety and Health, CDC; National Center for Health Statistics, CDC; U.S. Census Bureau.

All authors have completed and submitted the ICMJE form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

References

(1.) Rudd RA, Seth P, David F, Scholl L. Increases in drug and opioid-involved overdose deaths--United States, 2010-2015. MMWR Morb Mortal Wkly Rep 2016; 65:1445-52. https://doi.org/10.15585/mmwr. mm655051e1

(2.) Thumula V, Wang D, Liu T. Interstate variations in use of opioids. Report no. WC-17-28, 4th ed. Cambridge, MA: Workers Compensation Research Institute; 2017.

(3.) Bunn T, Bush A, Slavova S. Drug overdose deaths by specific employment industry, occupation, and drug type. J Ky Med Assoc 2014; 112:201-11.

(4.) Dissell R. Ohio construction workers seven times more likely to die of an opioid overdose in 2016. The Plain Dealer. November 6, 2017. http:// www.cleveland.com/metro/index.ssf/2017/11/ohio_construction_ workers_seven_times_more_likely_to_die_of_an_opioid_overdose_ in_2016.html

(5.) Harik V, Janiszewski M, Allen N. Analysis of opioid-related overdose deaths on Cape Cod, 2004-2014: implications for trades/service workers and the straight-to-work population. Barnstable, MA: Barnstable County Department of Human Services; 2017. https://www.bchumanservices. net/library/2017/10/BCDHS-Death-Certificate-Analysis-Final-Report10-5-17a.pdf

(6.) Funaiole P, Dustin L, Spencer P. Harnessing the tradition of brotherhood to reduce opioid overdose deaths among trade workers in Massachusetts. Presented at the National Prevention Network Annual Conference in Anaheim, CA; September 14, 2017. http://www.npnconference.org/ wp-content/uploads/2017/09/Funaiole-Dustin-Spencer.pdf

(7.) Alterman T, Luckhaupt SE, Dahlhamer JM, Ward BW, Calvert GM. Job insecurity, work-family imbalance, and hostile work environment: prevalence data from the 2010 National Health Interview Survey. Am J Ind Med 2013; 56:660-9. https://doi.org/10.1002/ajim.22123

(8.) Kowalski-McGraw M, Green-McKenzie J, Pandalai SP, Schulte PA. Characterizing the interrelationships of prescription opioid and benzodiazepine drugs with worker health and workplace hazards. J Occup Environ Med 2017; 59:1114-26. https://doi.org/10.1097/ JOM.0000000000001154

(9.) Frone MR. Prevalence and distribution of illicit drug use in the workforce and in the workplace: findings and implications from a U.S. national survey. J Appl Psychol 2006; 91:856-69. https://doi. org/10.1037/0021-9010.91.4.856

(10.) Bush DM, Lipari RN. Substance use and substance use disorder, by industry. Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration; 2015. https://www.samhsa.gov/data/sites/default/files/report_1959/ ShortReport-1959.pdf

Laurel Harduar Morano, PhD [1,2]; Andrea L. Steege, PhD [2]; Sara E. Luckhaupt, MD [2]

Corresponding author: Laurel Harduar Morano, LHarduarMorano@cdc.gov, 513-841-4487.

[1] Epidemic Intelligence Service, CDC; [2] Division of Surveillance, Hazard Evaluations and Field Studies, National Institute for Occupational Safety and Health, CDC.

* The Bureau of Labor Statistics provides work-related injury, illness, and fatality data by industry and occupation. https://www.bls.gov/iif/.

([dagger]) Participating states (participation years): Florida (2012), Georgia (2011, 2012), Hawaii (2007-2012), Idaho (2007-2012), Indiana (2007-2010), Kansas (2007-2012), Kentucky (2010-2012), Louisiana (2008-2010), Michigan (2007-2012), Nebraska (2007-2011), Nevada (2007-2012), New Hampshire (2007-2012), New Jersey (2007-2012), New Mexico (2007-2012), North Dakota (2008-2012), Ohio (2007-2012), Texas (2007-2010), Utah (2007-2012), Vermont (2012), Washington (2007-2012), and West Virginia (2007-2012)

([section]) 2012 is the most recent year for which NOMS data are available. NOMS is the largest source of U.S. population-level mortality data that contains occupation and industry information. Only 21 states contributed data to NOMS during the study period.

([paragraph]) From 2013 to 2014, a large increase in illicitly manufactured fentanyl occurred. Within the study period, this category is mostly recording information about pharmaceutical synthetic opioids.

** https://www2.census.gov/programs-surveys/demo/guidance/industryoccupation/occ2000t.pdf. The 1990 census occupation codes are available upon request from the NOMS program (https://www.cdc.gov/niosh/ topics/noms/).

([dagger][dagger]) The crosswalk is based on data in Table 2 of U.S. Census Bureau Technical Paper #65. https://www.census.gov/content/dam/Census/library/workingpapers/2003/demo/techpaper2000.pdf.

([section][section]) https://usa.ipums.org/usa/volii/occ2000.shtml.

([paragraph][paragraph]) Opioid overdose decedent median age = 43 years.

*** Homemaker (not working on a farm), volunteer, or student.

([dagger][dagger][dagger]) This category includes deaths with insufficient information available on the death certificate to apply a U.S. Census occupation code or for which the usual occupation field was left blank.

([section][section][section]) The proportional distribution of drugs (i.e., the proportion of total drug overdoses deaths for each drug type) involved in drug overdose deaths include opioids and nonopioids (e.g., cocaine). PMRs are mutually dependent and a higher proportion for one cause (e.g., a specific drug) results in a lower proportion for another cause. In this analysis, cause-specific outcomes (e.g., heroin-related overdose or prescription opioid-related overdose) are not independent and are partially overlapping. Decedents might have multiple drug types within their system at time of death and therefore counted in more than one cause-specific outcome category.

([paragraph][paragraph][paragraph]) Construction occupation group.

**** Construction first-line supervisors and managers = census 2000 occupation code 620; construction trade workers = census 2000 occupation codes 621-653; construction trade helpers = census 2000 occupation code 660; other construction and related workers = census 2000 occupation codes 666-676. https://www.cdc.gov/niosh/topics/coding/pdfs/2000_Census_ Occupation.pdf.

([dagger][dagger][dagger][dagger]) This occupation group includes supervisors/managers for both construction and extraction. A subcode to separate construction supervisors/managers from extraction supervisors/managers is not available.

([section][section][section][section]) Within "Industry," jobs are organized into categories by type of establishment/business whereas within "Occupation," jobs are organized into categories with similar job duties. For instance, within the 2016 construction industry, 62.4% were construction and extraction occupations, 9.7% were office and administrative support occupations, 6.2% were management occupations, and 3.2% were transportation and material moving occupations. (https://www.bls.gov/emp/ep_table_109.htm).

([paragraph][paragraph][paragraph][paragraph]) Illicit opioid means heroin or the use of prescription pain relievers in any way not directed by a doctor (does not include over-the-counter medications).

***** https://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-2016/ NSDUH-DetTabs-2016.pdf.

([dagger][dagger][dagger][dagger][dagger]) The Substance Abuse and Mental Health Services Administration (SAMHSA) provides detailed information on drug-free workplace programs, related laws and regulations, and a toolkit for employers (https:// www.samhsa.gov/workplace).
TABLE 1. Usual occupation group and mortality from unintentional or
undetermined drug overdoses * and drug overdoses involving heroin' or
opioid analgesics ([section])--National Occupational Mortality
Surveillance, United States, 2007-2012

U.S. Census 2000                                      Drug overdose *
occupation group

([paragraph])                            Total no.       Deaths
                                          of deaths
                                          observed     No. observed

Total                                     4,024,086           57,810
Management                                  325,123            2,458
Business operations                          38,740              349
Financial                                    51,795              390
Computer and                                 21,425              422
  mathematical
Architecture and                             88,825              580
  engineering
Life, physical, and social                   24,332              257
  science
Community and social                         39,046              381
  services
Legal                                        17,677              208
Education, training, and                    146,334              701
  library
Arts, design,                                48,331              929
  entertainment, sports,
  and media
Health care practitioners                   126,901            1,839
  and technical ([dagger][dagger])
Health care support ([section][section])     57,196            1,363
Protective service                           57,986              653
Food preparation and                        109,961            2,885
  serving ([section][section])
Building and grounds                        121,966            2,025
  cleaning and
  maintenance
Personal care                                67,288            1,333
  and service ([section][section])
Sales                                       287,191            3,413
Office and administrative                   345,607            2,861
  support
Farming, fishing, and                        27,421              354
  forestry
Construction ([section][section])           244,534            7,402
Extraction ([section][section])              19,536              431
Installation, maintenance,                  124,578            2,179
  and repair
Production                                  370,855            3,662
Transportation and                          276,558            4,370
  material moving
Military specific                            37,616              352
Nonpaid workers ([section][section])        856,256           13,001
Unknown ([section][section])                 91,008            3,012

U.S. Census 2000                             Drug overdose *
occupation group

([paragraph])                                   Deaths

                                              No. expected

Total                                     -- ([dagger][dagger])
Management                                             3,324.2
Business operations                                      496.2
Financial                                                575.2
Computer and                                             585.2
  mathematical
Architecture and                                         839.3
  engineering
Life, physical, and social                               301.8
  science
Community and social                                     449.3
  services
Legal                                                    254.3
Education, training, and                               1,187.8
  library
Arts, design,                                            898.7
  entertainment, sports,
  and media
Health care practitioners                              1,592.0
  and technical ([dagger][dagger])
Health care support ([section][section])               1,153.1
Protective service                                       909.7
Food preparation and                                   2,595.3
  serving ([section][section])
Building and grounds                                   2,090.4
  cleaning and
  maintenance
Personal care                                          1,207.3
  and service ([section][section])
Sales                                                  3,795.9
Office and administrative                              3,523.8
  support
Farming, fishing, and                                    482.4
  forestry
Construction ([section][section])                      5,902.5
Extraction ([section][section])                          370.8
Installation, maintenance,                             2,201.1
  and repair
Production                                             3,871.5
Transportation and                                     4,656.7
  material moving
Military specific                                        425.3
Nonpaid workers ([section][section])                  11,819.2
Unknown ([section][section])                           2,301.4

U.S. Census 2000                             Drug overdose *
occupation group

([paragraph])                                Standardized
                                             PMR (95% CI) **

Total                                     -- ([dagger][dagger])
Management                                    0.74 (0.71-0.77)
Business operations                           0.70 (0.63-0.78)
Financial                                     0.68 (0.61-0.75)
Computer and                                  0.72 (0.65-0.79)
  mathematical
Architecture and                              0.69 (0.64-0.75)
  engineering
Life, physical, and social                    0.85 (0.75-0.96)
  science
Community and social                          0.85 (0.77-0.94)
  services
Legal                                         0.82 (0.71-0.94)
Education, training, and                      0.59 (0.55-0.64)
  library
Arts, design,                                 1.03 (0.97-1.10)
  entertainment, sports,
  and media
Health care practitioners                     1.16 (1.10-1.21)
  and technical ([dagger][dagger])
Health care support ([section][section])      1.18 (1.12-1.25)
Protective service                            0.72 (0.66-0.78)
Food preparation and                          1.11 (1.07-1.15)
  serving ([section][section])
Building and grounds                          0.97 (0.93-1.01)
  cleaning and
  maintenance
Personal care                                 1.10 (1.05-1.17)
  and service ([section][section])
Sales                                         0.90 (0.87-0.93)
Office and administrative                     0.81 (0.78-0.84)
  support
Farming, fishing, and                         0.73 (0.66-0.81)
  forestry
Construction ([section][section])             1.25 (1.23-1.28)
Extraction ([section][section])               1.16 (1.06-1.28)
Installation, maintenance,                    0.99 (0.95-1.03)
  and repair
Production                                    0.95 (0.92-0.98)
Transportation and                            0.94 (0.91-0.97)
  material moving
Military specific                             0.83 (0.74-0.92)
Nonpaid workers ([section][section])          1.10 (1.08-1.12)
Unknown ([section][section])                  1.31 (1.26-1.36)

U.S. Census 2000                          Heroin ([dagger])
occupation group

([paragraph])                                 Deaths

                                            No. observed

Total                                                7,463
Management                                             232
Business operations                                     31
Financial                                               31
Computer and                                            57
  mathematical
Architecture and                                        62
  engineering
Life, physical, and social                              20
  science
Community and social                                    35
  services
Legal                                                   15
Education, training, and                                46
  library
Arts, design,                                          144
  entertainment, sports,
  and media
Health care practitioners                              109
  and technical ([dagger][dagger])
Health care support ([section][section])                116
Protective service                                      64
Food preparation and                                   486
  serving ([section][section])
Building and grounds                                   344
  cleaning and
  maintenance
Personal care                                          144
  and service ([section][section])
Sales                                                  405
Office and administrative                              261
  support
Farming, fishing, and                                   49
  forestry
Construction ([section][section])                    1,345
Extraction ([section][section])                         35
Installation, maintenance,                             319
  and repair
Production                                             514
Transportation and                                     710
  material moving
Military specific                                       41
Nonpaid workers ([section][section])                 1,324
Unknown ([section][section])                           524

U.S. Census 2000                            Heroin ([dagger])
occupation group

([paragraph])                                   Deaths

                                              No. expected

Total                                     -- ([dagger][dagger])
Management                                               383.2
Business operations                                       51.2
Financial                                                 57.5
Computer and                                              85.5
  mathematical
Architecture and                                         116.5
  engineering
Life, physical, and social                                37.9
  science
Community and social                                      48.6
  services
Legal                                                     24.1
Education, training, and                                 109.1
  library
Arts, design,                                            119.4
  entertainment, sports,
  and media
Health care practitioners                                139.3
  and technical ([dagger][dagger])
Health care support ([section][section])                  106.7
Protective service                                       125.6
Food preparation and                                     345.6
  serving ([section][section])
Building and grounds                                     294.7
  cleaning and
  maintenance
Personal care                                            125.4
  and service ([section][section])
Sales                                                    460.4
Office and administrative                                346.8
  support
Farming, fishing, and                                     66.1
  forestry
Construction ([section][section])                        922.9
Extraction ([section][section])                           43.9
Installation, maintenance,                               339.5
  and repair
Production                                               571.6
Transportation and                                       721.1
  material moving
Military specific                                         60.9
Nonpaid workers ([section][section])                   1,380.0
Unknown ([section][section])                             379.7

U.S. Census 2000                            Heroin ([dagger])
occupation group

([paragraph])                                Standardized
                                             PMR (95% CI) **

Total                                    -- ([dagger][dagger])
Management                                    0.61 (0.53-0.69)
Business operations                           0.61 (0.41-0.86)
Financial                                     0.54 (0.37-0.77)
Computer and                                   0.67 (0.5-0.86)
  mathematical
Architecture and                              0.53 (0.41-0.68)
  engineering
Life, physical, and social                    0.53 (0.32-0.81)
  science
Community and social                          0.72 (0.50-1.00)
  services
Legal                                         0.62 (0.35-1.03)
Education, training, and                      0.42 (0.31-0.56)
  library
Arts, design,                                 1.21 (1.02-1.42)
  entertainment, sports,
  and media
Health care practitioners                     0.78 (0.64-0.94)
  and technical ([dagger][dagger])
Health care support ([section][section])       1.09 (0.90-1.30)
Protective service                            0.51 (0.39-0.65)
Food preparation and                          1.41 (1.28-1.54)
  serving ([section][section])
Building and grounds                          1.17 (1.05-1.30)
  cleaning and
  maintenance
Personal care                                 1.15 (0.97-1.35)
  and service ([section][section])
Sales                                         0.88 (0.80-0.97)
Office and administrative                     0.75 (0.66-0.85)
  support
Farming, fishing, and                         0.74 (0.55-0.98)
  forestry
Construction ([section][section])             1.46 (1.38-1.54)
Extraction ([section][section])               0.80 (0.55-1.11)
Installation, maintenance,                    0.94 (0.84-1.05)
  and repair
Production                                    0.90 (0.82-0.98)
Transportation and                            0.98 (0.91-1.06)
  material moving
Military specific                             0.67 (0.48-0.91)
Nonpaid workers ([section][section])          0.96 (0.91-1.01)
Unknown ([section][section])                  1.38 (1.26-1.50)

U.S. Census 2000                             Prescription
occupation group                          opioid ([section])

([paragraph])                                  Deaths

                                             No. observed

Total                                                25,058
Management                                            1,106
Business operations                                     155
Financial                                               181
Computer and                                            187
  mathematical
Architecture and                                        265
  engineering
Life, physical, and social                              124
  science
Community and social                                    160
  services
Legal                                                    98
Education, training, and                                289
  library
Arts, design,                                           412
  entertainment, sports,
  and media
Health care practitioners                               876
  and technical ([dagger][dagger])
Health care support ([section][section])                626
Protective service                                      299
Food preparation and                                  1,207
  serving ([section][section])
Building and grounds                                    811
  cleaning and
  maintenance
Personal care                                           612
  and service ([section][section])
Sales                                                 1,515
Office and administrative                             1,341
  support
Farming, fishing, and                                   158
  forestry
Construction ([section][section])                     3,122
Extraction ([section][section])                         263
Installation, maintenance,                              950
  and repair
Production                                            1,544
Transportation and                                    1,680
  material moving
Military specific                                       142
Nonpaid workers ([section][section])                  5,783
Unknown ([section][section])                          1,152

U.S. Census 2000                              Prescription
occupation group                           opioid ([section])

([paragraph])                                   Deaths

                                              No. expected

Total                                    -- ([dagger][dagger])
Management                                             1,446.7
Business operations                                      213.2
Financial                                                254.6
Computer and                                             255.6
  mathematical
Architecture and                                         354.1
  engineering
Life, physical, and social                               133.8
  science
Community and social                                     190.4
  services
Legal                                                    116.1
Education, training, and                                 514.8
  library
Arts, design,                                            401.0
  entertainment, sports,
  and media
Health care practitioners                                709.2
  and technical ([dagger][dagger])
Health care support ([section][section])                  518.9
Protective service                                       382.7
Food preparation and                                   1,142.6
  serving ([section][section])
Building and grounds                                     888.9
  cleaning and
  maintenance
Personal care                                            540.3
  and service ([section][section])
Sales                                                  1,684.7
Office and administrative                              1,564.7
  support
Farming, fishing, and                                    222.1
  forestry
Construction ([section][section])                      2,573.0
Extraction ([section][section])                          201.7
Installation, maintenance,                               945.6
  and repair
Production                                             1,580.7
Transportation and                                     1,869.1
  material moving
Military specific                                        188.5
Nonpaid workers ([section][section])                   5,250.3
Unknown ([section][section])                             914.8

U.S. Census 2000                              Prescription
occupation group                           opioid ([section])

([paragraph])
                                              Standardized
                                             PMR (95% CI) **

Total                                    -- ([dagger][dagger])
Management                                    0.76 (0.72-0.81)
Business operations                           0.73 (0.62-0.85)
Financial                                     0.71 (0.61-0.82)
Computer and                                  0.73 (0.63-0.84)
  mathematical
Architecture and                              0.75 (0.66-0.84)
  engineering
Life, physical, and social                    0.93 (0.77-1.11)
  science
Community and social                          0.84 (0.72-0.98)
  services
Legal                                         0.84 (0.69-1.03)
Education, training, and                      0.56 (0.50-0.63)
  library
Arts, design,                                 1.03 (0.93-1.13)
  entertainment, sports,
  and media
Health care practitioners                     1.24 (1.15-1.32)
  and technical ([dagger][dagger])
Health care support ([section][section])       1.21 (1.11-1.30)
Protective service                             0.78 (0.7-0.88)
Food preparation and                          1.06 (1.00-1.12)
  serving ([section][section])
Building and grounds                          0.91 (0.85-0.98)
  cleaning and
  maintenance
Personal care                                 1.13 (1.04-1.23)
  and service ([section][section])
Sales                                         0.90 (0.85-0.95)
Office and administrative                     0.86 (0.81-0.90)
  support
Farming, fishing, and                         0.71 (0.60-0.83)
  forestry
Construction ([section][section])             1.21 (1.17-1.26)
Extraction ([section][section])               1.30 (1.15-1.47)
Installation, maintenance,                    1.00 (0.94-1.07)
  and repair
Production                                    0.98 (0.93-1.03)
Transportation and                            0.90 (0.86-0.94)
  material moving
Military specific                             0.75 (0.63-0.89)
Nonpaid workers ([section][section])          1.10 (1.07-1.13)
Unknown ([section][section])                  1.26 (1.19-1.33)

Abbreviations: CI = confidence interval; NOMS = National Occupational
Mortality Surveillance; PMR = proportionate mortality ratio.

* Deaths were classified using the International Classification of
Diseases, Tenth Revision (ICD-10). Drug overdose deaths were
identified using underlying cause-of death codes X40-X44
(unintentional) and Y10-Y14 (unknown intent).

([dagger]) Drug overdose deaths, as defined, that have heroin (T40.1)
as a contributing cause.

([section]) Drug overdose deaths, as defined, that have prescription
opioids (T40.2-T40.4) as a contributing cause.

([paragraph]) Occupation groups presented in ascending 2000 census
code order (e.g., Management = 001-043);
https://usa.ipums.org/usa/volii/occ2000.shtml.

** Indirectly standardized to the standard population of all NOMS
deaths with occupation information by age, sex, race (white, black,
other), calendar year (2007-2012), and state.

([dagger][dagger]) Not applicable.

([section][section]) PMR significantly above 1.00 for drug overdose
deaths in these categories.

TABLE 2. Usual occupation group and mortality from unintentional and
undetermined drug overdoses * involving natural and semisynthetic
opioids ([dagger]), methadone ([section]), or synthetic opioids other
than methadone ([paragraph])--National Occupational Mortality
Surveillance, United States, 2007-2012

U.S. Census 2000             Total no.    Natural and
occupation group **          of deaths   semisynthetic
                             observed      opioids *

                                            Deaths

                                         No. observed

Total                       4,024,086          16,603
Management                    325,123             747
Business operations            38,740             111
Financial                      51,795             132
Computer and                   21,425             120
  mathematical
Architecture and               88,825             178
  engineering
Life, physical, and social     24,332              85
  science
Community and social           39,046             100
  services
Legal                          17,677              73
Education, training, and      146,334             215
  library
Arts, design,                  48,331             268
  entertainment, sports,
  and media
Health care practitioners     126,901             565
  and technical
Health care support            57,196             396
Protective service             57,986             216
Food preparation and          109,961             765
  serving
Building and grounds          121,966             544
  cleaning and
  maintenance
Personal care and service      67,288             411
Sales                         287,191           1,039
Office and administrative     345,607             908
  support
Farming, fishing, and          27,421             103
  forestry
Construction                  244,534           2,013
Extraction                     19,536             208
Installation, maintenance,    124,578             631
  and repair
Production                    370,855           1,018
Transportation and            276,558           1,084
  material moving
Military specific              37,616              87
Nonpaid workers               856,256           3,841
Unknown                        91,008             745

U.S. Census 2000                   Natural and
occupation group **               semisynthetic
                                    opioids *

                                     Deaths

                                  No. expected

Total                        -- ([section][section])
Management                                    965.5
Business operations                           139.8
Financial                                     170.6
Computer and                                  167.1
  mathematical
Architecture and                              230.3
  engineering
Life, physical, and social                     88.0
  science
Community and social                          126.8
  services
Legal                                          78.2
Education, training, and                      346.4
  library
Arts, design,                                 264.8
  entertainment, sports,
  and media
Health care practitioners                     474.5
  and technical
Health care support                           339.5
Protective service                            257.0
Food preparation and                          744.9
  serving
Building and grounds                          591.7
  cleaning and
  maintenance
Personal care and service                     361.1
Sales                                       1,118.5
Office and administrative                   1,042.3
  support
Farming, fishing, and                         140.0
  forestry
Construction                                1,696.2
Extraction                                    149.7
Installation, maintenance,                    625.8
  and repair
Production                                  1,034.0
Transportation and                          1,227.8
  material moving
Military specific                             122.3
Nonpaid workers                             3,485.7
Unknown                                       614.6

U.S. Census 2000                   Natural and
occupation group **               semisynthetic
                                    opioids *

                                Standardized PMR
                                    (95% CI)
                               ([dagger][dagger])

Total                        -- ([section][section])

Management                         0.77 (0.72-0.83)
Business operations                0.79 (0.65-0.96)
Financial                          0.77 (0.65-0.92)
Computer and                       0.72 (0.60-0.86)
  mathematical
Architecture and                   0.77 (0.66-0.90)
  engineering
Life, physical, and social         0.97 (0.77-1.19)
  science
Community and social               0.79 (0.64-0.96)
  services
Legal                              0.93 (0.73-1.17)
Education, training, and           0.62 (0.54-0.71)
  library
Arts, design,                      1.01 (0.89-1.14)
  entertainment, sports,
  and media
Health care practitioners          1.19 (1.09-1.29)
  and technical
Health care support                1.17 (1.05-1.29)
Protective service                 0.84 (0.73-0.96)
Food preparation and               1.03 (0.96-1.10)
  serving
Building and grounds               0.92 (0.84-1.00)
  cleaning and
  maintenance
Personal care and service          1.14 (1.03-1.25)
Sales                              0.93 (0.87-0.99)
Office and administrative          0.87 (0.82-0.93)
  support
Farming, fishing, and              0.74 (0.60-0.89)
  forestry
Construction                       1.19 (1.14-1.24)
Extraction                         1.39 (1.21-1.59)
Installation, maintenance,         1.01 (0.93-1.09)
  and repair
Production                         0.98 (0.93-1.05)
Transportation and                 0.88 (0.83-0.94)
  material moving
Military specific                  0.71 (0.57-0.88)
Nonpaid workers                    1.10 (1.07-1.14)
Unknown                            1.21 (1.13-1.30)

U.S. Census 2000             Methadone (dagger])
occupation group **

                                   Deaths

                                No. observed

Total                                     7,504
Management                                  326
Business operations                          34
Financial                                    40
Computer and                                 51
  mathematical
Architecture and                             75
  engineering
Life, physical, and social                   31
  science
Community and social                         46
  services
Legal                                        18
Education, training, and                     50
  library
Arts, design,                               125
  entertainment, sports,
  and media
Health care practitioners                   199
  and technical
Health care support                         197
Protective service                           76
Food preparation and                        400
  serving
Building and grounds                        249
  cleaning and
  maintenance
Personal care and service                   205
Sales                                       422
Office and administrative                   366
  support
Farming, fishing, and                        54
  forestry
Construction                              1,075
Extraction                                   42
Installation, maintenance,                  304
  and repair
Production                                  470
Transportation and                          548
  material moving
Military specific                            41
Nonpaid workers                           1,705
Unknown                                     355

U.S. Census 2000               Methadone (dagger])
occupation group **

                                     Deaths

                                  No. expected

Total                        -- ([section][section])
Management                                    433.0
Business operations                            63.8
Financial                                      74.3
Computer and                                   81.2
  mathematical
Architecture and                              114.0
  engineering
Life, physical, and social                     43.1
  science
Community and social                           55.7
  services
Legal                                          34.2
Education, training, and                      143.6
  library
Arts, design,                                 124.5
  entertainment, sports,
  and media
Health care practitioners                     198.1
  and technical
Health care support                           152.4
Protective service                            115.9
Food preparation and                          357.3
  serving
Building and grounds                          265.4
  cleaning and
  maintenance
Personal care and service                     159.0
Sales                                         507.2
Office and administrative                     450.2
  support
Farming, fishing, and                          80.5
  forestry
Construction                                  805.2
Extraction                                     45.8
Installation, maintenance,                    293.2
  and repair
Production                                    477.7
Transportation and                            572.6
  material moving
Military specific                              62.8
Nonpaid workers                             1,527.7
Unknown                                       265.7

U.S. Census 2000              Methadone (dagger])
occupation group **

                                Standardized PMR
                                    (95% CI)
                               ([dagger][dagger])

Total                        -- ([section][section])
Management                        0.75 (0.67-0.84)
Business operations               0.53 (0.37-0.74)
Financial                         0.54 (0.38-0.73)
Computer and                      0.63 (0.47-0.83)
  mathematical
Architecture and                  0.66 (0.52-0.82)
  engineering
Life, physical, and social        0.72 (0.49-1.02)
  science
Community and social              0.83 (0.60-1.10)
  services
Legal                             0.53 (0.31-0.83)
Education, training, and          0.35 (0.26-0.46)
  library
Arts, design,                     1.00 (0.84-1.20)
  entertainment, sports,
  and media
Health care practitioners         1.00 (0.87-1.15)
  and technical
Health care support               1.29 (1.12-1.49)
Protective service                0.66 (0.52-0.82)
Food preparation and              1.12 (1.01-1.23)
  serving
Building and grounds              0.94 (0.83-1.06)
  cleaning and
  maintenance
Personal care and service         1.29 (1.12-1.48)
Sales                             0.83 (0.75-0.92)
Office and administrative         0.81 (0.73-0.90)
  support
Farming, fishing, and             0.67 (0.50-0.87)
  forestry
Construction                      1.34 (1.26-1.42)
Extraction                        0.92 (0.66-1.24)
Installation, maintenance,        1.04 (0.92-1.16)
  and repair
Production                        0.98 (0.90-1.08)
Transportation and                0.96 (0.88-1.04)
  material moving
Military specific                 0.65 (0.47-0.89)
Nonpaid workers                   1.12 (1.06-1.17)
Unknown                           1.34 (1.20-1.48)

U.S. Census 2000               Synthetic opioids
occupation group **               other than
                             methadone ([section])

                                    Deaths

                                 No. observed

Total                                       3,966
Management                                    177
Business operations                            29
Financial                                      28
Computer and                                   35
  mathematical
Architecture and                               32
  engineering
Life, physical, and social                     22
  science
Community and social                           34
  services
Legal                                          18
Education, training, and                       65
  library
Arts, design,                                  60
  entertainment, sports,
  and media
Health care practitioners                     229
  and technical
Health care support                           106
Protective service                             49
Food preparation and                          180
  serving
Building and grounds                          119
  cleaning and
  maintenance
Personal care and service                      89
Sales                                         229
Office and administrative                     233
  support
Farming, fishing, and                          23
  forestry
Construction                                  416
Extraction                                     41
Installation, maintenance,                    132
  and repair
Production                                    237
Transportation and                            235
  material moving
Military specific                              28
Nonpaid workers                               946
Unknown                                       174

U.S. Census 2000                Synthetic opioids
occupation group **                other than
                              methadone ([section])

                                     Deaths

                                  No. expected

Total                        -- ([section][section])
Management                                    223.7
Business operations                            36.2
Financial                                      41.9
Computer and                                   37.4
  mathematical
Architecture and                               51.6
  engineering
Life, physical, and social                     18.7
  science
Community and social                           31.3
  services
Legal                                          18.4
Education, training, and                       89.0
  library
Arts, design,                                  57.9
  entertainment, sports,
  and media
Health care practitioners                     126.3
  and technical
Health care support                            93.4
Protective service                             55.0
Food preparation and                          176.3
  serving
Building and grounds                          137.3
  cleaning and
  maintenance
Personal care and service                      87.5
Sales                                         261.5
Office and administrative                     269.0
  support
Farming, fishing, and                          28.4
  forestry
Construction                                  366.3
Extraction                                     33.2
Installation, maintenance,                    135.0
  and repair
Production                                    256.6
Transportation and                            283.2
  material moving
Military specific                              23.5
Nonpaid workers                               887.7
Unknown                                       139.7

U.S. Census 2000                Synthetic opioids
occupation group **                other than
                              methadone ([section])

                                Standardized PMR
                                    (95% CI)
                               ([dagger][dagger])

Total                        -- ([section][section])
Management                         0.79 (0.68-0.92)
Business operations                0.80 (0.54-1.15)
Financial                          0.67 (0.44-0.97)
Computer and                       0.94 (0.65-1.30)
  mathematical
Architecture and                   0.62 (0.42-0.88)
  engineering
Life, physical, and social         1.18 (0.74-1.78)
  science
Community and social               1.09 (0.75-1.52)
  services
Legal                              0.98 (0.58-1.54)
Education, training, and           0.73 (0.56-0.93)
  library
Arts, design,                      1.04 (0.79-1.33)
  entertainment, sports,
  and media
Health care practitioners          1.81 (1.59-2.06)
  and technical
Health care support                1.13 (0.93-1.37)
Protective service                 0.89 (0.66-1.18)
Food preparation and               1.02 (0.88-1.18)
  serving
Building and grounds               0.87 (0.72-1.04)
  cleaning and
  maintenance
Personal care and service          1.02 (0.82-1.25)
Sales                              0.88 (0.77-1.00)
Office and administrative          0.87 (0.76-0.98)
  support
Farming, fishing, and              0.81 (0.51-1.22)
  forestry
Construction                       1.14 (1.03-1.25)
Extraction                         1.23 (0.89-1.67)
Installation, maintenance,         0.98 (0.82-1.16)
  and repair
Production                         0.92 (0.81-1.05)
Transportation and                 0.83 (0.73-0.94)
  material moving
Military specific                  1.19 (0.79-1.72)
Nonpaid workers                    1.07 (1.00-1.14)
Unknown                            1.25 (1.07-1.44)

Abbreviations: CI = confidence interval; NOMS = National Occupational
Mortality Surveillance; PMR = proportionate mortality ratio.

* Deaths were classified using the International Classification of
Diseases, Tenth Revision (ICD-10). Drug overdose deaths were
identified using underlying cause-of death codes X40-X44
(unintentional) and Y10-Y14 (unknown intent).

([dagger]) Drug overdose deaths, as defined, with natural and
semisynthetic opioids (T40.2) as a contributing cause.

([section] Drug overdose deaths, as defined, with methadone (T40.3)
as a contributing cause.

([paragraph]) Drug overdose deaths, as defined, with synthetic
opioids other than methadone (T40.4) as a contributing cause. This
category includes legal and illegal fentanyl along with other
synthetic opioids.

** Occupation groups presented in ascending 2000 census code order
(e.g., Management = 001-043);
https://usa.ipums.org/usa/volii/occ2000.shtml.

([dagger][dagger]) Indirectly standardized to the standard population
of all NOMS deaths with occupation information by age, sex, race
(white, black, other), calendar year (2007-2012), and state.

([section][section]) Not applicable.

TABLE 3. Construction occupation subgroup * and mortality from
unintentional and undetermined drug overdoses ([dagger]) by drug type
--National Occupational Mortality Surveillance, United States,
2007-2012

                                First-line supervisors/managers

                                  No.
Opioid type                     observed   PMR (95% CI) ([section])

Total                            24,306           -- ([paragraph])
Overdose                            338           0.94 (0.84-1.05)
Heroin **                            44           0.88 (0.64-1.18)
Prescription opioids                148           0.96 (0.81-1.12)
  ([section][section])
Natural semisynthetic                92            0.9 (0.72-1.10)
  ([paragraph][paragraph])
Methadone ***                        49           1.01 (0.75-1.33)
Synthetic                            27           1.26 (0.83-1.83)
  ([dagger][dagger][dagger])

                                Construction trades workers

                                  No.
Opioid type                     observed   PMR (95% CI) ([section])

Total                           213,029           -- ([paragraph])
Overdose                          6,901           1.28 (1.25-1.31)
Heroin **                         1,282           1.51 (1.42-1.59)
Prescription opioids              2,911           1.23 (1.19-1.28)
  ([section][section])
Natural semisynthetic             1,876           1.21 (1.15-1.26)
  ([paragraph][paragraph])
Methadone ***                     1,007           1.36 (1.28-1.45)
Synthetic                           383           1.14 (1.03-1.26)
  ([dagger][dagger][dagger])

                                Helpers, construction

                                         No.
Opioid type                           observed

Total                                            419
Overdose                                          26
Heroin **                       -- ([dagger][dagger])
Prescription opioids                              12
  ([section][section])
Natural semisynthetic                              6
  ([paragraph][paragraph])
Methadone ***                   -- ([dagger][dagger])
Synthetic                       -- ([dagger][dagger])
  ([dagger][dagger][dagger])

                                Helpers, construction

Opioid type                     PMR (95% CI) ([section])

Total                                  -- ([paragraph])
Overdose                               1.31 (0.85-1.91)
Heroin **                         -- ([dagger][dagger])
Prescription opioids                   1.42 (0.73-2.48)
  ([section][section])
Natural semisynthetic                  1.07 (0.39-2.32)
  ([paragraph][paragraph])
Methadone ***                     -- ([dagger][dagger])
Synthetic                         -- ([dagger][dagger])
  ([dagger][dagger][dagger])

                                Other construction and
                                   related workers

                                         No.
Opioid type                            observed

Total                                           6,780
Overdose                                          137
Heroin **                                          15
Prescription opioids                               51
  ([section][section])
Natural semisynthetic                              39
  ([paragraph][paragraph])
Methadone ***                                      15
Synthetic                       -- ([dagger][dagger])
  ([dagger][dagger][dagger])

                                 Other construction and
                                    related workers

Opioid type                     PMR (95% CI) ([section])

Total                                  -- ([paragraph])
Overdose                               1.15 (0.97-1.36)
Heroin **                              0.84 (0.47-1.38)
Prescription opioids                   1.00 (0.74-1.31)
  ([section][section])
Natural semisynthetic                  1.16 (0.82-1.58)
  ([paragraph][paragraph])
Methadone ***                          0.93 (0.52-1.53)
Synthetic                         -- ([dagger][dagger])
  ([dagger][dagger][dagger])

Abbreviations: CI = confidence interval; NOMS = National Occupational
Mortality Surveillance; PMR = proportionate mortality ratio.

* Construction first-line supervisors and managers = census 2000
occupation code 620; construction trade workers = census 2000
occupation codes 621-653; construction trade helpers = census 2000
occupation code 660; other construction and related workers = census
2000 occupation codes 666-676.

([dagger]) Deaths were classified using Internationa! Classification
of Diseases, Tenth Revision (ICD-10J. Drug overdose deaths were
identified using underlying cause-of death codes X40-X44
(unintentional) and Y10-Y14 (unknown intent).

([section]) Indirectly standardized to the standard population of all
NOMS deaths with occupation information by age, sex, race (white,
black, other), calendar year (2007-2012), and state.

([paragraph]) Not applicable.

** Drug overdose deaths, as defined, that have heroin (T40.1) as a
contributing cause.

([dagger][dagger]) Observations <5 are not shown. PMRs were not
calculated.

([section][section]) Drug overdose deaths, as defined, that have
prescription opioids (T40.2-T40.4) as a contributing cause.

([paragraph][paragraph]) Drug overdose deaths, as defined, that have
natural and semisynthetic opioids (T40.2) as a contributing cause.

*** Drug overdose deaths, as defined, that have methadone (T40.3) as
a contributing cause.

([dagger][dagger][dagger][dagger]) Drug overdose death, as defined,
that have synthetic opioids other than methadone (T40.4) as a
contributing cause. This category includes legal and illegal fentanyl
along with other synthetic opioids.
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Author:Morano, Laurel Harduar; Steege, Andrea L.; Luckhaupt, Sara E.
Publication:Morbidity and Mortality Weekly Report
Date:Aug 24, 2018
Words:7360
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