According to a January 2016 CDC report,1 Rose A. Rudd, Noah Aleshire, Jon E. Zibbell, R. Matthew Gladden. “Increases in Drug and Opioid Overdose Deaths — United States, 2000–2014.” CDC MMWR January 1, 2016 (December 18 early release) / 64(50);1378-82. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm over 47,000 Americans fatally overdosed on prescription opioid pain killers in 2014. This is a stunning fact. But almost as stunning is the apparent lack of concern expressed by the world’s media when reporting it. The National Council on Alcoholism and Drug Dependence, for example, thought it worth a mere 214 words.2 “More Than 47,000 Americans Died From Drug Overdoses in 2014.” NCADD. 16 December 2015. (20 Feb 2016.” http://www.ncadd.org/blogs/in-the-news/more-than-47-000-americans-died-from-drug-overdoses-in-2014 NBC News was obviously more excited and pushed their coverage to a hefty 223 words.3 Associated Press. “Drug Overdose Deaths Surge 7 Percent in US.” NBC News. Dec 10 2015. (Accessed 20 Feb 2016.) http://www.nbcnews.com/health/health-news/drug-overdose-deaths-surge-7-percent-us-n478091 And even those who pushed their word totals up slightly higher ignored the real stories hidden behind the headlines.
With that in mind, let’s take a look at the CDC report in detail–which virtually no news service did–and then explore the backstory that was pretty much ignored outside of a couple of surprising journalistic players. And finally, I want to take a look a stunning twist to the story that absolutely no one looked at but that to my mind is really the most important takeaway from the whole debacle.
The CDC Report on Increases in Drug and Opioid Overdose Deaths
First of all, let’s make note of the fact that the CDC report is not 200 words long, but 3200 words long. In movie-speak, that means that when the media reported on the story, they left most of it on the cutting room floor. So, what got dumped? As it turns out: the details. And as they say, the Devil is in the details. In broad terms, according to the report, the rate for drug overdose deaths has increased approximately 140% since 2000, driven largely by opioid overdose deaths. This epidemic isn’t being driven by illicit drugs, but by a surge in the use of prescription opioid painkillers. According to government statistics, nearly 1.9 million Americans now abuse or are dependent on legal opioids. On the slightly positive side, after increasing steadily every year since the 1990s, deaths involving the most commonly prescribed opioid pain relievers declined slightly in 2012 and remained steady in 2013, showing some signs of progress. Unfortunately, that pause was brief as drug overdose deaths jumped significantly in the last year of the study–from 2013 to 2014. In fact, in 2014, 19,000 people fatally overdosed on prescription painkillers, which represents a 16 percent increase over 2013. Increases in opioid overdose deaths were the main factor in the increase in drug overdose deaths. The death rate from the most commonly prescribed opioid pain relievers (natural and semisynthetic opioids) increased 9%. Concomitantly, the death rate from heroin increased 26%, and the death rate from synthetic opioids, a category that includes illicitly manufactured fentanyl and synthetic opioid pain relievers other than methadone, increased 80%. Nearly every aspect of the opioid overdose death epidemic worsened in 2014. And then there’s heroin. In fact, heroin overdose deaths have been sharply increasing since 2010. Surprisingly, as we will discuss later, heroin overdose deaths may not mean quite what you think they mean.
Now, as bad as those broad statistics are, the details behind this epidemic of drug overdose deaths are even worse. Since 2000, the rate of deaths from drug overdoses has increased 137%, including a 200% increase in the rate of overdose deaths involving both opioid pain relievers and heroin. During 2014, a total of 47,055 drug overdose deaths occurred in the United States. From 2013 to 2014, the largest increase in the rate of drug overdose deaths involved synthetic opioids, other than methadone (i.e., fentanyl and tramadol), which nearly doubled from 1.0 per 100,000 to 1.8 per 100,000. Meanwhile, as already stated, heroin overdose death rates increased by 26% from 2013 to 2014 and have more than tripled since 2010, from 1.0 per 100,000 in 2010 to 3.4 per 100,000 in 2014.
As the CDC report explained, from 2000 to 2014, nearly half a million persons in the United States died from drug overdoses. But it gets worse. The killer statistic is that more people died from drug overdoses in the United States in 2014 than during any previous year on record. In 2014, there were approximately one and a half times more drug overdose deaths in the United States than deaths from motor vehicle crashes or gun violence.4 Wide-ranging online data for epidemiologic research (WONDER). CDC, National Center for Health Statistics; 2015. Available at http://wonder.cdc.gov Let that sink in for a moment. Again, we’re talking about prescription pain relievers and heroin as the main drugs associated with these overdose deaths, and, surprise, those heroin deaths are likely connected to prescription pain relievers, not to junkies on the street. In summary, the 2014 data demonstrates that the United States’ opioid overdose epidemic includes two distinct but interrelated trends: a 15-year increase in overdose deaths involving prescription opioid pain relievers and a recent surge in illicit opioid overdose deaths, driven largely by heroin.
But what does that mean?
Drug overdose deaths involving heroin have continued to climb sharply, with heroin overdoses more than tripling in 4 years. This increase mirrors large increases in heroin use across the country and has been shown to be closely tied to opioid pain reliever misuse and dependence. Past misuse of prescription opioids is the strongest risk factor for heroin initiation and use, specifically among persons who report past-year dependence or abuse.5 Jones CM, Logan J, Gladden RM, Bohm MK. “Vital signs: demographic and substance use trends among heroin users–United States, 2002–2013.” MMWR 2015;64:719–25. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6426a3.htm As it turns out, the increased availability of heroin, combined with its relatively low price and high purity (compared with diverted prescription opioids) appear to be major drivers of the upward trend in heroin use and overdose.6 Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. “The changing face of heroin use in the United States: a retrospective analysis of the past fifty years.” JAMA Psychiatry 2014;71:821–6. http://archpsyc.jamanetwork.com/article.aspx?articleid=1874575 Finally, illicit fentanyl is often combined with heroin or sold as heroin. Illicit fentanyl might be contributing to recent increases in drug overdose deaths involving heroin. Therefore, increases in illicit fentanyl-associated deaths might represent an emerging and troubling feature of the rise in illicit opioid overdoses that has been driven by heroin.
Bottom line: we’re not talking about your typical junkies now, but average people (your friends, neighbors, and co-workers) migrating from prescription pain killers prescribed by their doctors to addiction and then to heroin–and dying as a result.
The Backstory Available to Anyone Who Looked
In the old days, when reporters actually worked stories and practiced journalism, they would have run with the CDC report (heck, they would have actually looked at the CDC report itself rather than merely copying the AP summary of that report) and dug into the story behind it–perhaps even turning it into a series of reports exposing the underbelly of what has grown to become one of the leading causes of death in the United States. But that’s when reporters were paid to actually ask questions.
Today, not so much.
In fact, very few media outlets made any attempt to go the extra mile. Two that did were Business Insider7 Harrison Jacobs. “The explosion in overdoses from legal drugs is changing how doctors treat pain — but it may not be enough.” Business Insider. 28 Feb 2016. (Accessed 28 Feb 2016.) http://www.businessinsider.com/opioid-and-heroin-epidemic-is-changing-pain-treatment-2016-2 and The Week magazine, whose staff, in their February 19th issue, pushed beyond the preliminaries to report that it was medical doctors who had fueled this crisis of addiction and deadly overdoses by freely doling out prescription painkillers over the years.8 The Week Staff. “America’s painkiller epidemic, explained.” The Week. February 13, 2016. (Accessed 14 Feb 2016.) http://theweek.com/articles/605224/americas-painkiller-epidemic-explained
As stated in their article, “Addiction experts say doctors have fueled this crisis by recommending that patients with even minor ailments and aches take highly addictive opioids like Vicodin, Percocet, and OxyContin. Physicians wrote 259 million opioid prescriptions in 2012, triple the number two decades ago and enough to provide every adult in the country with a bottle of these pills.” They then went into the history behind prescription painkillers. I’ve expanded upon it.
For centuries–before pharmaceutical drugs–people relied on natural pain killers like opium. In fact, laudanum, which is a tincture made from opium, was used as a painkiller as far back as the 1500s until it fell out of favor because of its addictive nature. It was replaced by morphine, an opium isolate that Merck began marketing in 1827. Unfortunately, morphine is even more addictive than laudanum, which caused it too to fall out of favor. Amazingly, morphine was replaced by heroin, which was marketed by Bayer as a non-addictive opioid alternative–despite the fact that it is synthesized from morphine and is two to four times stronger than morphine. Nevertheless, doctors believed the marketing hype and prescribed heroin extensively from the late 1800s to the early 1900s. Obviously, it soon became abundantly clear that heroin was anything but non-addictive. This provided yet another opening for the pharmaceutical companies, which they grabbed onto with a vengeance.
In 1917, three years before heroin was banned in the US, oxycodone was developed by two German scientists. Oxycodone is a semisynthetic opioid synthesized from an alkaloid found in the Persian poppy. In 1939, it was introduced to the US, but it was not until 1950 when it was combined with aspirin and sold as Percodan that it really took off as American physicians began to prescribe it by the truckload. By 1963, the state of California had determined that one-third of all drug addiction in the state was the result of Percodan abuse. Nevertheless, it still took another seven years before the DEA classified it as a Schedule II drug with a high potential for abuse.
Moving on, Percocet and its close cousin Vicodin became the next prescription opioids of choice. Theoretically, they were only to be used for managing pain during terminal illnesses such as cancer, or for acute short-term pain, like recovery from surgery–to ensure patients wouldn’t get addicted. But, as The Week explained, in the 1990s, doctors came under increasing pressure to use opioids–particularly Purdue Pharma’s new drug OxyContin–to treat the millions of Americans suffering from chronic nonmalignant conditions, like back pain and osteoarthritis. Sensing a marketing opportunity, the National Pharmaceutical Council released a report that actually reframed pain as the “fifth vital sign” that doctors needed to monitor…and treat. In response, numerous “pill mills” began to pop up all over the country. Pill mills are shady doctor’s offices, clinics, or health care facilities that routinely conspire in the over-prescribing and dispensing of controlled substances outside the scope of the prevailing standards. In other words, they don’t ask too many questions. The bottom line is that the increased availability and acceptability of opioid drugs led to an explosion in prescriptions. Dr. Russell Portenoy, an influential New York–based pain specialist, helped lead the campaign. He claimed prescription opioids were a “gift from nature,” and assured his fellow doctors–based on his own 1986 study of just 38 patients–that fewer than 1 percent of long-term users became addicted.9 Portenoy RK, Foley KM. “Chronic use of opioid analgesics in non-malignant pain: Report of 38 cases.” Pain. 1986;25:171–186. http://www.ncbi.nlm.nih.gov/pubmed/2873550
Purdue Pharma made similar claims for its own drug, OxyContin, and promoted it like diet cola. As The Week reported:
“In fact, when OxyContin went on sale in 1996, Purdue launched a “promotional campaign unlike [anything] we have ever really seen,” says opioid abuse expert Dr. Andrew Kolodny. The company gave doctors 34,000 coupons for free OxyContin prescriptions, bombarded them with branded stuffed toys and coffee mugs, and aggressively promoted the idea that the new drug, which is stronger than morphine, was both safe and highly effective. “Drug reps were going to family-care doctors and insisting that OxyContin had no real risks — only benefits,” says Kolodny. Purdue pleaded guilty in 2007 to criminal charges that it misled regulators, doctors, and patients about OxyContin’s addictive qualities. But by that point, hundreds of thousands of Americans were hooked.”
By 2011, according to an IMS Health National Prescription Audit, 219 million opioid prescriptions were being handed out each year.10 Nora D. Volkow. “Prescription Opioid and Heroin Abuse.” NIH. April 29, 2014. (Accessed 28 Feb 2016.) http://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2015/prescription-opioid-heroin-abuse At that point, the prescription painkiller crisis could no longer be ignored, and federal, state, and local law enforcement began to crack down on both drug abusers and doctors who over-prescribe and pressed for the establishment of prescription drug monitoring programs that make it more difficult for drug abusers to get prescriptions from more than one doctor. The number of states with prescription drug monitoring programs has more than doubled, from 20 states in 2006 to 48 states now. Unfortunately, no good deed goes unpunished.
Which Leads Us to Heroin
The crackdown on opioid prescriptions that followed the OxyContin debacle has had a deadly unintended consequence: It has made heroin de rigueur painkiller of choice. As regulation of prescription painkillers has tightened and pill mills have been shut down, an increasing number of the hundreds of thousands of newly minted prescription opioid addicts have been driven to look for opioids on the black market — and then, inevitably, to heroin, which at $5 a bag is much cheaper than a $40 pill. “People eventually say, ‘Why am I paying $1 per milligram for Oxy when for a tenth of the price I can get an equivalent dose of heroin?'” says addiction specialist Dr. Jason Jerry. Four out of five of today’s heroin addicts were hooked on opioids first.
Now, that’s a pretty interesting backstory, and kudos to Business Insider and The Week for actually practicing journalism and digging into it. But as it happens, I think they missed an even bigger backstory associated with the CDC report.
The Big Twist
To me, the biggest story here is the fact that so many news services released what are, effectively, identical articles about the CDC report. To be sure, I’ve discussed this phenomenon before. And no, it has nothing to do with government conspiracies or suppression of evidence by the giant pharmaceutical companies. In fact, the truth is much simpler, much more mundane, and far more unsettling.
Quite simply, the reason that this story was so universally under-reported is that thanks to the internet and the fact that everyone now looks to get their news online for free, investigative journalism is a dying art. When people insist on getting their news for free, who’s going to pay for real journalism. Instead, all of the world’s newspapers, magazines, and television stations have become, by and large, news aggregators. They collect stories from the Associated Press and Reuters and, quite simply, shift a few words around, slap a new title on the piece, and publish it as their own. When it came to the CDC report, almost none of them went to the CDC report, as easy as that would have been. Instead, they went no further than the Associated Press summary of it which was sent out to all of their paid subscribers–i.e., those same newspapers, magazines, and TV stations we just talked about. Let me clarify this for you. As I mentioned earlier, the CDC report was 3,200 hundred words. The Associated Press article condensed that to 304 words. Here’s the complete 304 word summary of the CDC report as delivered by the AP.11 MIKE STOBBE. “Painkillers, heroin drive increase in US overdose deaths.” AP Dec. 10, 2015. (Accessed 25 Feb 2016.) http://bigstory.ap.org/article/e1b453e5622744708eae9175daad5e55/painkillers-heroin-drive-increase-us-overdose-deaths
NEW YORK (AP) — Drug overdoses rose again last year, driven by surges in deaths from heroin and powerful prescription painkillers, according to new federal statistics.
Overdose deaths in the U.S. surpassed 47,000 — up 7 percent from the previous year.
Many of the deaths were due to a group of powerful opioid painkillers, long the leading cause of fatal overdoses. But the number had been stable recently while heroin deaths grew. Experts have speculated that addicts migrated from painkillers to cheaper and easier-to-get heroin.
But last year, the opioid toll rose to nearly 19,000 deaths, an increase of 16 percent.
Heroin deaths continued to climb, by 28 percent to about 10,500.
The new government statistics also indicate upticks in deaths from sedatives and cocaine, but those numbers are less than the deaths from the opioids and heroin.
The Centers for Disease Control and Prevention this week posted the tally, which is based on death certificates.
The federal agency is analyzing the drug numbers to determine what’s behind last year’s increases, said CDC Director Dr. Tom Frieden. But clearly, he added, the nation’s drug overdose problem “is not getting better.”
Opioid pain relievers, including methadone, OxyContin and Vicodin, have been the focus of a government campaign. The CDC has urged doctors to limit their use to the most serious forms of pain, such as cancer patients and end-of-life care. But the vast majority of prescriptions written in the U.S. are for more common ailments like arthritis and back pain.
The CDC is working on new guidelines for doctors for prescribing such drugs.
CDC officials believe at least some of the increase in painkiller deaths last year may be due to illegally-made fentanyl, which is a synthetic form of morphine. Fentanyl may also be contributing to the heroin numbers, in cases in which heroin is laced with fentanyl, Frieden added.
Now follow any of the links below to see how the major news services did nothing more than take what they were given by the AP and republish it–adding nothing to the story.
- NBC News12 “Drug Overdose Deaths Surge 7 Percent in US.” NBC News Health. Dec 10 2015. (Accessed 25 Feb 2016.) http://www.nbcnews.com/health/health-news/drug-overdose-deaths-surge-7-percent-us-n478091
- Chicago Tribune13 “Report: Drug overdose deaths surged in 14 states last year.” Chicago Tribune. December 18, 2015. (Accessed 25 Feb 2016.) http://www.chicagotribune.com/lifestyles/health/ct-drug-overdose-deaths-surge-20151218-story.html
- CTV News14 “Drug overdoses surge across U.S.: Centres for Disease Control and Prevention.” CTV News Health. December 19, 2015. (Accessed 25 Feb 2016.) http://www.ctvnews.ca/health/drug-overdoses-surge-across-u-s-centres-for-disease-control-and-prevention-1.2707084
- Fox News15 “Painkillers, heroin drive increase in US overdose deaths.” Fox News. December 11, 2015. (Accessed 25 Feb 2016.) http://www.foxnews.com/health/2015/12/11/painkillers-heroin-drive-increase-in-us-overdose-deaths.html
- USA Today16 “Heroin, painkillers drive increase in overdose deaths.” USA Today. December 12, 2015. (25 Feb 2016.) http://www.usatoday.com/story/news/2015/12/12/heroin-painkillers-drive-increase-overdose-deaths/77186790/
Again, we’re not talking about a grand conspiracy–merely economics.
But that brings up another question: if everything starts with the Associated Press in this case, who controls the story at AP? What panel of experts or editors makes the choices as to what tidbits to ignore from the CDC report and what to include? Who decides what expert gets called in to comment on the story–or even if any expert should get called? As it turns out, there is no panel of experts, no editorial overseers. There is just Mike Stobbe! And who is Mike Stobbe that he should wield such control over the health information that is parceled out to us? In fact, he’s just a medical writer who’s worked for AP for the last 11 years–and done the same thing for a number of other health issues.17 http://bigstory.ap.org/content/mike-stobbe
Is he an evil man in thrall to the pharmaceutical companies? Not at all. Again, he’s just a health writer, a member of the Association of Health Care Journalists no less, merely doing his job. And his job is to take complex studies and reports concerning medicine, nutrition, and health as they are released and condense them down to their essence, stripping away all complexity and nuance, so that they are easily comprehended by the news organizations that subscribe to AP–and the general public that ultimately reads his reports when they are republished by those same organizations. And therein lies the problem. He is not paid to question the validity of the studies he reports on, nor is he paid to explore backstories. In fact, he is paid to keep his reports short and simple.
And since the studies and press releases he reports on are exclusively issued by researchers and members of the medical/pharmaceutical establishment and government organizations such as the CDC, FDA, and NIH, that means that, de facto, Mike applies a pro-government, pro-medicine, anti-alternative health filter to every task he performs for the Associated Press. That’s why Mike didn’t look for a backstory and insert that backstory into his summary. No such backstory was indicated in his source material. And if Mike didn’t provide it in his story, why would any of AP’s media subscribers think to do so?
And now comes the devastating conclusion.
Mike’s job description, as well as his biases and interpretations of studies, ultimately shape your opinions–and, more importantly, the opinions of all the world’s legislators and government bureaucrats that read the AP articles based on his summaries. And make no mistake, that influence is extensive. In fact, it’s worldwide. That’s right: Mike’s take on the CDC report was picked up by newspapers and news agencies around the world–including countries you would not imagine–and reprinted almost exactly as Mike wrote it.
- BBC News18 “Drug overdose deaths in the US reach record levels.” BBC News. 18 December 2015. (25 Feb 2016.) http://www.bbc.com/news/world-us-canada-35138647
- New Zealand Herald19 “Drug overdose deaths surge across the US.” New Zealand Herald. Dec 19, 2015. (25 Feb 2016.) http://www.nzherald.co.nz/lifestyle/news/article.cfm?c_id=6&objectid=11563685
- The Japan Times20 “Drug overdose deaths surge across U.S.” The Japan Times. (Accessed 25 Feb 2016.) http://www.japantimes.co.jp/news/2015/12/19/world/science-health-world/drug-overdose-deaths-surge-across-u-s/
- Iran Daily21 “US drug industry, doctors contribute to overdose deaths: Professor.” Iran Daily. 20 Dec 2015. (25 Feb 2016.) http://www.iran-daily.com/News/133324.html
So, do I have a problem with Mike personally? Not at all. I’m sure he’s a nice guy, and as far as AP is concerned, does his job well. After all, he’s worked for them for 11 years. But the problem I have is that no one elected him to this position as the world’s “health censor.” No one outside of AP gets to influence his take on health issues. Quite simply, AP’s requirements and Mike’s biases ultimately shape government policy and legislation–and make no mistake, they do. And it’s not just Mike; Will Dunham does the same thing for Reuters.22 http://www.reuters.com/journalists/will-dunham What that means is that a couple of people control what hundreds of major news services and papers around the world say about any particular health and nutrition issue–almost word for word. By extension then, they also indirectly control the laws that legislatures enact. Think about it. When legislators see that every major newspaper and TV station is saying the same thing, then what are they to think other than “it must be true?” Res Ipsa loquitur! The thing speaks for itself.
Now consider the fact that the Associated Press and Reuters, for whatever reason (and you can take your pick from any listed above), frequently get it wrong when reporting on studies and government reports. They either misunderstand the study itself or tag it with a catchy but misleading headline. In any case, it’s wrong, and when they get it wrong, the world’s media gets it wrong; and when the world’s media gets it wrong, governments, legislators, and regulators get it wrong. For example:
- Are Supplements Safe?
- Vitamin D Nonsense
- Weight Loss is Difficult
- The Attack on Dr. Oz
- Cancer and Bad Luck
- Organic VS Conventional
And that, as they now say, is a “yuuuge problem.”
|↑1||Rose A. Rudd, Noah Aleshire, Jon E. Zibbell, R. Matthew Gladden. “Increases in Drug and Opioid Overdose Deaths — United States, 2000–2014.” CDC MMWR January 1, 2016 (December 18 early release) / 64(50);1378-82. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm|
|↑2||“More Than 47,000 Americans Died From Drug Overdoses in 2014.” NCADD. 16 December 2015. (20 Feb 2016.” http://www.ncadd.org/blogs/in-the-news/more-than-47-000-americans-died-from-drug-overdoses-in-2014|
|↑3||Associated Press. “Drug Overdose Deaths Surge 7 Percent in US.” NBC News. Dec 10 2015. (Accessed 20 Feb 2016.) http://www.nbcnews.com/health/health-news/drug-overdose-deaths-surge-7-percent-us-n478091|
|↑4||Wide-ranging online data for epidemiologic research (WONDER). CDC, National Center for Health Statistics; 2015. Available at http://wonder.cdc.gov|
|↑5||Jones CM, Logan J, Gladden RM, Bohm MK. “Vital signs: demographic and substance use trends among heroin users–United States, 2002–2013.” MMWR 2015;64:719–25. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6426a3.htm|
|↑6||Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. “The changing face of heroin use in the United States: a retrospective analysis of the past fifty years.” JAMA Psychiatry 2014;71:821–6. http://archpsyc.jamanetwork.com/article.aspx?articleid=1874575|
|↑7||Harrison Jacobs. “The explosion in overdoses from legal drugs is changing how doctors treat pain — but it may not be enough.” Business Insider. 28 Feb 2016. (Accessed 28 Feb 2016.) http://www.businessinsider.com/opioid-and-heroin-epidemic-is-changing-pain-treatment-2016-2|
|↑8||The Week Staff. “America’s painkiller epidemic, explained.” The Week. February 13, 2016. (Accessed 14 Feb 2016.) http://theweek.com/articles/605224/americas-painkiller-epidemic-explained|
|↑9||Portenoy RK, Foley KM. “Chronic use of opioid analgesics in non-malignant pain: Report of 38 cases.” Pain. 1986;25:171–186. http://www.ncbi.nlm.nih.gov/pubmed/2873550|
|↑10||Nora D. Volkow. “Prescription Opioid and Heroin Abuse.” NIH. April 29, 2014. (Accessed 28 Feb 2016.) http://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2015/prescription-opioid-heroin-abuse|
|↑11||MIKE STOBBE. “Painkillers, heroin drive increase in US overdose deaths.” AP Dec. 10, 2015. (Accessed 25 Feb 2016.) http://bigstory.ap.org/article/e1b453e5622744708eae9175daad5e55/painkillers-heroin-drive-increase-us-overdose-deaths|
|↑12||“Drug Overdose Deaths Surge 7 Percent in US.” NBC News Health. Dec 10 2015. (Accessed 25 Feb 2016.) http://www.nbcnews.com/health/health-news/drug-overdose-deaths-surge-7-percent-us-n478091|
|↑13||“Report: Drug overdose deaths surged in 14 states last year.” Chicago Tribune. December 18, 2015. (Accessed 25 Feb 2016.) http://www.chicagotribune.com/lifestyles/health/ct-drug-overdose-deaths-surge-20151218-story.html|
|↑14||“Drug overdoses surge across U.S.: Centres for Disease Control and Prevention.” CTV News Health. December 19, 2015. (Accessed 25 Feb 2016.) http://www.ctvnews.ca/health/drug-overdoses-surge-across-u-s-centres-for-disease-control-and-prevention-1.2707084|
|↑15||“Painkillers, heroin drive increase in US overdose deaths.” Fox News. December 11, 2015. (Accessed 25 Feb 2016.) http://www.foxnews.com/health/2015/12/11/painkillers-heroin-drive-increase-in-us-overdose-deaths.html|
|↑16||“Heroin, painkillers drive increase in overdose deaths.” USA Today. December 12, 2015. (25 Feb 2016.) http://www.usatoday.com/story/news/2015/12/12/heroin-painkillers-drive-increase-overdose-deaths/77186790/|
|↑18||“Drug overdose deaths in the US reach record levels.” BBC News. 18 December 2015. (25 Feb 2016.) http://www.bbc.com/news/world-us-canada-35138647|
|↑19||“Drug overdose deaths surge across the US.” New Zealand Herald. Dec 19, 2015. (25 Feb 2016.) http://www.nzherald.co.nz/lifestyle/news/article.cfm?c_id=6&objectid=11563685|
|↑20||“Drug overdose deaths surge across U.S.” The Japan Times. (Accessed 25 Feb 2016.) http://www.japantimes.co.jp/news/2015/12/19/world/science-health-world/drug-overdose-deaths-surge-across-u-s/|
|↑21||“US drug industry, doctors contribute to overdose deaths: Professor.” Iran Daily. 20 Dec 2015. (25 Feb 2016.) http://www.iran-daily.com/News/133324.html|