What Every Clinician Needs to Know About Overdoses April 10-12, 2012 Walt Disney World Swan Resort
Learning Objectives:1. Describe the characteristics and risk factorsthat may predispose patients to an overdose.2. State the value of Poison Control Centerdata in formulating strategies to reduceprescription drug diversion health careassociated problems.
Disclosure Statement• Erin Johnson wishes to disclose the following:• Contract work with Miller Medical Communication, LLC.• No other relevant, real or apparent personal or professional financial relationships.
Common Characteristics Among Rx Opioid Overdose Decedents Erin Johnson, MPH, Utah Department of Health
In a nutshell• Those who die from overdose of prescription opioids: – Suffer from pain – Use more often than rx’d – Lack social support – Have been diagnosed with mental illness – Smoke – Have received treatment for substance abuse• Screen for/be aware of characteristics – Closely monitor high risk patients or choose alternatives to opioids• Educate on using as directed
Utah News Clippings about Prescription Drug Death
Legislation in 2007• Research – Causes, risk factors, solutions• Prescribing Guidelines – “medical treatment and quality care guidelines that are scientifically based; and peer reviewed”• Educate – Health care providers, Patients, Insurers, Public
To prevent and reduce themisuse and abuse ofprescription pain medications inUtah by providing informationand strategies regarding safeuse, safe storage, and safedisposal of these potentiallydangerous drugs.
Social Support• 65.9% were separated/divorced, widowed, or unmarried• 70.7% attended church less than monthly• 63.2% were unemployed during last 2 months prior to death• 23.2% lived alone at time of death
Potential Indicators of Misuse• 52.9% took pain meds more often than prescribed• 31.6% visited >1 doctor to get more rx pain medication• 39.6% received rx pain meds from source other than healthcare provider• 29.8% used rx pain meds for reasons other than to treat pain
Complaints and Concerns• 21.1% complained that provider was not prescribing enough pain medication• 32.5% had a healthcare provider raise concerns about decedent’s use of pain medication• 75.5% said others were concerned about decedent’s use of pain medication
Mental Health• 54.3% diagnosed with mental illness (in lifetime) – 40.6% mood disorder – 15.4% anxiety disorder• 24.4% hospitalized for mental illness
Substance Use• 73.2% smoked daily at time of death• 61.4% had used an illicit substance (ever)• 53.1% received treatment for any substance abuse (ever)
Conclusions• Characteristics to keep in mind when starting/continuing opioids: – Hx of substance abuse? Tx? – Daily smoker? – Mental illness? – Social support system?
Conclusions….(cont.)• Things to discuss with patients: – Dangers of using more often than prescribed – Talk with family?
Study Objective and Design Identify risk factors for death People who died from prescription opioids People who used prescription opioids Compared populations
Data Sources: Decedents Medical examiner records Death certificates Next-of-kin interviews
Decedents (N = 254) October 26, 2008–October 25, 2009 Prescription opioid cause of death Accidental or intent-undetermined manner of death Utah residents ≥18 years of age Interview completed by next-of-kin
Data Source: Comparison Group Behavioral Risk Factor Surveillance System (BRFSS) Self-reported Landline only Non-institutionalized Weighted to reflect state population Prescription pain medication questions added 2008
Comparison Group (N = 1,308) Utah 2008 BRFSS Used prescription opioid in prior 12 months Utah residents ≥18 years of age
Statistical Methods Exposure prevalence (prevalence of characteristics) Exposure prevalence ratios (EPR) as measure of association Decedent prevalence EPR = Comparison prevalence 95% Confidence intervals (CI)
Pain Medication Source and Use Prevalence (%) EPRCharacteristic Decedents Comparison (95% CI) Obtained 0.8 80.3 96.2via prescription (0.8–0.9) Obtained 4.3 35.8 8.3via other source (3.2–5.4)Used more than 16.5 52.9 3.2 prescribed (9.3–23.7)
Pain Type among Decedents No Acute pain pain 9% 8% Chronic pain 83%
Chronic Pain Comparison (Obtained via Prescription) Decedents (N = 191) Comparison (N = 1253) Acutepain only Acute 6% pain only 78% Chronic Chronic pain pain 94% 32% EPR = 3.0 (95% CI = 2.7–3.3)
Numbers of Drugs as Decedent CODs (N = 254) Number of Percentage ofNumber of Drugs Decedents Decedents (%) 1 56 22.0 2 56 22.0 3 76 29.9 4 44 17.3 ≥5 22 8.7
Illicit Substance Use History (Lifetime) among Decedents (N = 251) Number of Percentage ofType of Drugs Decedents Decedents (%) Heroin 52 20.7 Cocaine 77 30.7 Any illicit 154 61.4 substanceIllicit substance 129 51.4 use treatment
Alcohol Use and Cause of Death 88% of decedents ever drank 14% of decedents drank daily in last 2 months 2% of comparison group drank daily in last month COD among decedents: 10%
Education and Smoking Prevalence (%) EPRCharacteristic Decedents Comparison (95% CI) Did not graduate 3.0 18.5 6.2from high school (2.0–3.9) 5.6 Smoked daily 54.5 9.7 (4.4–6.9) Smoked daily 5.0 (education- 49.1 9.7 (4.0–6.1) adjusted)
Marital Status and Health Insurance Prevalence (%) EPRCharacteristic Decedents Comparison (95% CI) Divorced/ 3.7 34.6 9.4 Separated (3.0–4.4) 2.3 Uninsured 29.2 12.5 (1.8–2.8)
Prescription Opioid Use and Chronic Pain Use outside prescription increases risk Not all decedents used outside prescription Majority of decedents obtained by prescription Chronic pain in majority of decedents Prevalence higher if obtained via prescription
Education and Smoking Low education level Predispose to lack of insurance and other factors Smoking rates higher among low educated Association mildly confounded by education Smoking rates higher among substance abusers Could confound association Population susceptible to addiction
Marital Status and Health Insurance Divorced/separated Indicates lack of social support Increase risky drug use Decrease chance of timely care Lack of health insurance Limits access to care Consequence of chronic pain or substance abuse
Limitations Interview response influences Social desirability Recall Lack of knowledge about decedents Incomplete comparability of data sources Potential risk factors not analyzed Illicit substance use Mental illness Confounding variables
Conclusion Risk of death complicated Use outside prescription bounds risky Decedents needed chronic pain therapy Other factors important Providers can recognize risk and control exposure
Recommendations Prescribers should screen chronic pain patients Update screening tools to include risk factors Continue research on risk factors Smoking Illicit substance use Mental illness
Acknowledgments Comparison data prepared by William Lanier, EIS Utah Department of Health: Todd Grey Robert Rolfs Jonathan Anderson Kris Russell Michael Friedrichs