Advanced analytics work in epidemiology comparing the linear correlation in birth cohort prevalence and incidence for high-risk drug poisoning indicators using population health methods.

1. Association of High Risk Prescription
Drug Behavior and Behavioral Risk
Factors by Birth Year Cohort
Fan Xiong
Senior Epidemiologist
Kansas Data-Driven Prevention Initiative
Program
Kansas Board of Pharmacy, Kansas Tracking
and Reporting of Controlled Substances
(KTRACS)
Kansas Department of Health and
Environment, Bureau of Health Promotion

3. Kansas
Almost 3 out of 100 Kansans
have misused prescription (Rx)
pain medication in the past
year.
Source: 2015 Kansas Behavioral Risk Factor Surveillance Survey

4. Most said pain was the reason for misuse, but
some Kansans cited a reason other than pain,
such as the feeling it caused.

5. Drug Poisoning
Deaths in Kansas by
Gender
Kansas Female:
274%
Age-adjusted
mortality rate
ratio: 3.74 (95%
CI: 2.63 – 5.32).
Kansas Male:
114%
Age-adjusted
mortality rate
ratio: 2.14 (95%
CI: 1.63 – 2.81).
In 2014, the age-adjusted
poisoning mortality rate
was significantly higher
for both Kansas females
and males when
compared to 2000.

6. Image Source: CDC.gov/drugoverdose
What are the key risk factors?

7. Image Source: Huang X, Keyes KM, Li G. Increasing Prescription Opioid and Heroin Overdose Mortality in the United States, 1999–2014: An Age–Period–Cohort
Analysis. American journal of public health. 2018 Jan;108(1):131-6.
“Individuals
born between
1947 and 1964
and between
1979 and 1992
are particularly
afflicted by the
opioid
epidemic.”
– Huang, et al.
Age-Period-Cohort Analysis of Prescription Opioid and Heroin Poisoning Deaths

20. High Risk Prescription Drug Behavior
and Drug Poisoning Deaths Associated
with Gender and Birth Year Cohort
Fan Xiong
Senior Epidemiologist
Kansas Data-Driven Prevention Initiative
Program
Kansas Board of Pharmacy, Kansas Tracking
and Reporting of Controlled Substances
(KTRACS)
Kansas Department of Health and
Environment, Bureau of Health Promotion

21. Population:
Kansans born from 1940 to 1989 in 2011 to 2016
(excluding 2013 due to incomplete KTRACS data)
High Risk Prescription Drug Behaviors:
Rate per 100,000 Population
KTRACS
2011-2012 and 2014-2016 data
Kansas Board of Pharmacy
Any overlapping
opioid and
benzodiazepine
prescription drugs per
calendar quarter
Any overlapping
opioid and muscle
relaxant prescription
drugs per calendar
quarter
5+ prescribers and 5+
dispensers per
calendar quarter for all
Schedule II to IV Drugs
Drug Poisoning Deaths:
Rate per 100,000 Population
Kansas Mortality File
2011-2012 and 2014-2016 data
Bureau of Epidemiology and Public Health
Informatics, Kansas Department of Health
and Environment
Drug poisoning deaths
with any drugs or
substance as a
contributing cause of
death
Method and Data Source

22. Figure 3. Percent of Deaths due to Drug Poisoning by Year of Death, Gender, and Birth Cohort, Kansas residents with a birth
year from 1940 to 1989, 2011-2016
More than 10% of all deaths are
due to drug poisonings for
Kansas birth cohorts after 1970.
Year of Death
Birth Cohorts

23. Figure 4b. FAST-LTS Linear Regression Estimated Drug Poisoning Mortality Rates and Overlapping Opioids and Muscle
Relaxant Patient Rate per 100,000 population by Year, Kansas Female residents with a birth year from 1940 to 1989, 2011-2016
For Kansas females, the drug poisoning and overlapping opioid
and muscle relaxant birth cohorts DO SHARE a similar
decreasing and increasing relationship centered on the 1957
cohorts.
Females

24. Figure 4c. FAST-LTS Linear Regression Estimated Drug Poisoning Mortality Rates and Overlapping Opioid and Benzo Patient
Episodes Rate per 100,000 population by Year, Kansas Female residents with a birth year from 1940 to 1989, 2011-2016
For Kansas females, the drug poisoning and overlapping opioid and benzo birth cohorts DO
SHARE a similar decreasing relationship for birth cohorts after 1970 cohorts.
Females

25. Figure 5b. FAST-LTS Linear Regression Estimated Drug Poisoning Mortality Rates and Overlapping Opioids and Muscle
Relaxant Patient Rate per 100,000 population by Year, Kansas Male residents with a birth year from 1940 to 1989, 2011-2016
For Kansas males, the drug poisoning and
overlapping opioid and muscle relaxant birth
cohorts DO SHARE a similar decreasing and
increasing relationship UNTIL the 1965 birth
cohort.
Males

26. Figure 5c. FAST-LTS Linear Regression Estimated Drug Poisoning Mortality Rates and Overlapping Opioid and Benzo Patient
Episodes Rate per 100,000 population by Year, Kansas Male residents with a birth year from 1940 to 1989, 2011-2016
For Kansas males, the drug poisoning and
overlapping opioid and benzo birth cohorts
DO NOT SHARE any similar increasing or
decreasing relationship.
Males

27. The Role of Controlled Substance
Prescription Drugs as a Factor in Drug
Poisoning Deaths
High-risk prescription drug behaviors may be able to explain
partially some of the increase in drug poisoning deaths among
Kansas females and Kansas males.
Correlated high risk prescription drug behaviors of interest
includes: Having 5+ prescribers and 5+ dispensers,
overlapping opioid and muscle relaxant (carisoprodol)
prescriptions, and overlapping opioid and benzo prescriptions.

28. What does the result imply?
Patients with multiple provider episodes (5+ prescribers and 5+
dispensers) in a calendar year may have similar characteristics to
population who used illicit drugs, such as diverted prescriptions,
heroin, or potentially methamphetamine (classified as amphetamine-
related) for females and males born between 1940 and 1994.
The rapid increase in drug poisoning deaths for cohorts born after
the 1970s does not seem to be directly related to prescription drug
use. However, other characteristics of these populations (e.g., health
care access, income, education, health behaviors, etc.) might explain
their illicit drug use patterns.

29. Prescription drug-related deaths seems
mostly concentrated among Kansans
born between 1955 and 1974.
Illicit drug-related poisoning
deaths seems mostly
concentrated among Kansans
born between 1974 and 1999
with a differential impact from
high-risk prescription drug
behaviors when compared to
Kansans born between 1955
and 1974.
Conclusions
• possibly diverted
prescription drugs,
• heroin, and/or
• methamphetamine
Illicit drugs
can include
any of the
following:

30. Next Steps
Explore linkage of controlled substance prescription
drug data to mortality-toxicology files.
Use toxicology results to assess the sensitivity and
specificity of controlled substance prescription drug
indicators impact on drug poisoning deaths.
Explore whether the association between high-risk
prescription drug behaviors continues to explain
approximately 60% to 90% of drug poisoning-related
deaths.
Implications
• There was not a strong linear association
between certain high-risk prescription drug
behavior indicators and the rise in heroin or
amphetamine related deaths.
• Linkage of PDMP data to mortality files
alone may not be able to fully explain the
impact of controlled substance prescription
drug behaviors on illicit drug poisoning
deaths.
• Illicit drug poisoning deaths are occurring
more frequently among cohorts with
possibly different drug utilization behaviors.