摘要：We review evidence of determinants contributing to increased opioid-related mortality in the United States and Canada between 1990 and 2013. We identified 17 determinants of opioid-related mortality and mortality increases that we classified into 3 categories: prescriber behavior, user behavior and characteristics, and environmental and systemic determinants. These determinants operate independently but interact in complex ways that vary according to geography and population, making generalization from single studies inadvisable. Researchers in this area face significant methodological difficulties; most of the studies in our review were ecological or observational and lacked control groups or adjustment for confounding factors; thus, causal inferences are difficult. Preventing additional opioid-related mortality will likely require interventions that address multiple determinants and are tailored to specific locations and populations. During the past 2 decades, mortality resulting from unintentional prescription drug overdoses has risen steeply in the United States and Canada and is now widely recognized as a major public health problem. Deaths involving prescription opioid analgesics, including hydrocodone, oxycodone, hydromorphone, and methadone, have surpassed deaths from heroin and cocaine combined. 1 In 2010, the 11th consecutive year in which drug overdose deaths increased, 75% of all pharmaceutical overdose deaths involved opioids, and prescription opioids were involved in 16 651 deaths in the United States, a more than 4-fold increase since 1999. 2–4 Although national data are unavailable for Canada, in Ontario opioid-related mortality doubled between 1991 and 2007, and by 2004 it was more than double the HIV/AIDS mortality rate (27.2 vs 12 per million). 5 Although this problem is most acute in North America, it has the potential, amid calls to increase worldwide access to opioids, 6–8 to become a serious global health problem. Identifying the determinants of increased mortality is an essential step in reducing opioid-related deaths in the United States and Canada and curbing future increases worldwide. However, although much has been written about this phenomenon, the evidence base is fragmented and complex, extant reviews are unsystematic and idiosyncratic, 9–11 and media coverage is often highly sensationalized. Our aim was to systematically identify and review evidence regarding determinants of increased opioid-related mortality in the United States and Canada between 1990 and 2013.
