Also Appearing in This Issue of JAMA


Opioid Analgesics Involved in Most Pharmaceutical Overdose Deaths

“Data recently released by the National Center for Health Statistics show drug overdose deaths increased for the 11th consecutive year in 2010. Pharmaceuticals, especially opioid analgesics, have driven this increase. Other pharmaceuticals are involved in opioid overdose deaths, but their involvement is less well characterized,” writes Christopher M. Jones, Pharm.D., of the Centers for Disease Control and Prevention, Atlanta, and colleagues.

As reported in a Research Letter, the authors used data from the National Vital Statistics System multiple cause-of-death file to examine the specific drugs involved in pharmaceutical and opioid-related overdose deaths. The researchers found that in 2010, there were 38,329 drug overdose deaths in the United States; most (22,134; 57.7 percent) involved pharmaceuticals; 9,429 (24.6 percent) involved only unspecified drugs. “Of the pharmaceutical-related overdose deaths, 16,451 (74.3 percent) were unintentional, 3,780 (17.1 percent) were suicides, and 1,868 (8.4 percent) were of undetermined intent. Opioids (16,651; 75.2 percent), benzodiazepines (6,497; 29.4 percent), antidepressants (3,889; 17.6 percent), and antiepileptic and anti-parkinsonism drugs (1,717; 7.8 percent) were the pharmaceuticals (alone or in combination with other drugs) most commonly involved in pharmaceutical overdose deaths.”

“This analysis confirms the predominant role opioid analgesics play in pharmaceutical overdose deaths, either alone or in combination with other drugs. It also, however, highlights the frequent involvement of drugs typically prescribed for mental health conditions such as benzodiazepines, antidepressants, and antipsychotics in overdose deaths. People with mental health disorders are at increased risk for heavy therapeutic use, nonmedical use, and overdose of opioids. Screening, identification, and appropriate management of such disorders is an important part of both behavioral health and chronic pain management. Tools such as prescription drug monitoring programs and electronic health records can help clinicians to identify risky medication use and inform treatment decisions, especially for opioids and benzodiazepines.”

(JAMA. 2013;309[7]:657-659. Available pre-embargo to the media at


Viewpoints in This Issue of JAMA

Reengineering U.S. Health Care

Ari Hoffman, M.D., of the University of California, San Francisco, and Ezekiel J. Emanuel, M.D., Ph.D., of the University of Pennsylvania, Philadelphia, write that “health reform requires fixing a chronically dysfunctional system. While it is tempting to try to identify a single solution to this complex problem, the cure will require a multimodality approach with a focus on reengineering the entire care delivery process.”

In this Viewpoint, the authors examine the issue of reengineering the U.S. health care system. “With a focus on reengineering, the nation may succeed not only in implementing systematic health care reform, but reform that actually improves the health of Americans while simultaneously controlling unsustainable costs.”

(JAMA. 2013;309[7]:661-662. Available pre-embargo to the media at

Please Note: An author podcast on this article will be available post-embargo on the JAMA website.


Treatment of Atherosclerotic Renal Artery Stenosis

Peter W. de Leeuw, M.D., Ph.D., of the University Hospital Maastricht and Cardiovascular Research Institute Maastricht, the Netherlands, and colleagues discuss the diagnosis and treatment of atheroscle­rotic renal artery stenosis.

“From a scientific perspective, it is worthwhile to explore whether angioplasty added to optimal anti-atherosclerotic treatment will produce a better outcome in terms of renal function than medical treatment alone. This could be investigated in a clinical trial conducted among patients with hypertension and low-grade renal artery stenosis. On a broader scale, failure of trials to show an expected outcome should serve as motivation to reconsider the pathophysiological principles behind the treatment rather than abandon the treatment.”

(JAMA. 2013;309[7]:663-664. Available pre-embargo to the media at


Policy Responses to Demand for Health Care Access

Katherine Diaz Vickery, M.D., of the University of Michigan, Ann Arbor, and colleagues write that the Emergency Medical Treatment and Active Labor Act (EMTALA), signed into law in 1986, was “intended by Congress to impart a social contract between the health care-seeking public and a U.S. health care system that the public progressively distrusted.”

“Examining where and how EMTALA fell short highlights how the Affordable Care Act can start to construct a system founded on shared societal obligations to health. The path forward in U.S. health care reform lies in recognizing the shared ethical standard that supersedes political differences.”

(JAMA. 2013;309[7]:665-666. Available pre-embargo to the media at


Realigning Reimbursement Policy and Financial Incentives to Support Patient-Centered Out-of-Hospital Care

“… little consideration has been given to how fee-for-service reimbursement in out-of-hospital care limits the ability of emergency medical services (EMS) to provide more patient-centered care and reduce downstream health care costs,” writes Kevin Munjal, M.D., M.P.H., of the Mount Sinai Medical Center, New York, and Brendan Carr, M.D., M.S., of the University of Pennsylvania, Philadelphia.

“Current Medicare reimbursement policies for out-of-hospital care link payment to transport to an emergency department. This provides a disincentive for EMS agencies to work to reduce avoidable visits to emergency departments, limits the role of prehospital care in the U.S. health system, is not responsive to patients’ needs, and generates downstream health care costs. Financial and delivery model reforms that address EMS payment policy may allow out-of-hospital care systems to deliver higher-quality, patient-centered, coordinated health care that could improve the public health and lower costs.”

(JAMA. 2013;309[7]:667-668. Available pre-embargo to the media at


Editor’s Note: Please see the articles for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

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