Erin Johnson

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What Every Clinician Needs to Know About Overdoses
National Rx Drug Abuse Summit 4-10-12

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Erin Johnson

  1. 1. What Every Clinician Needs to Know About Overdoses April 10-12, 2012 Walt Disney World Swan Resort
  2. 2. 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.
  3. 3. 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.
  4. 4. Common Characteristics Among Rx Opioid Overdose Decedents Erin Johnson, MPH, Utah Department of Health
  5. 5. 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
  6. 6. Utah News Clippings about Prescription Drug Death
  7. 7. 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
  8. 8. 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.
  9. 9. Bear Trap
  10. 10. Number of Unintentional PrescriptionOpioid Drug Overdose Cases by Year: Utah, 2000-2010Utah Medical Examiner Data
  11. 11. What we knew•  ME data: –  Sex –  BMI –  Age –  Drugs involved
  12. 12. What we wanted to know•  Was there a common profile?•  How much of the problem was: –  Misuse/abuse –  Using only as directed•  Who should be the target of our educational efforts?
  13. 13. What we did•  Next-of-kin interviews•  Worked under Medical Examiner –  Determine manner of death•  Interviews over telephone
  14. 14. Study Population•  Died: October 26, 2008 – October 25, 2009•  Drug as primary cause of death•  Accidental or undetermined manner of death•  Utah residents•  ≥12 years of age
  15. 15. Study Population Flowchart 432 drug deaths 268 (62%) prescription opioid COD
  16. 16. Study Population Flowchart 432 drug deaths 278 (64%) prescription opioid COD 233 (87%) prescription opioid COD, no illicit drug COD
  17. 17. Study Population Flowchart 432 drug deaths 278 (64%) prescription opioid COD 254 (91%) prescription opioid COD with completed interview
  18. 18. Legitimate need•  91.7% (222) took rx pain meds for pain during the year prior to death•  80.3% (204) obtained pain meds from healthcare provider during last year of life
  19. 19. Demographics•  53.2% male•  79.1% between ages 25-54•  66.9% overweight (BMI>25)
  20. 20. 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
  21. 21. 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
  22. 22. Two Face
  23. 23. 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
  24. 24. Mental Health•  54.3% diagnosed with mental illness (in lifetime) –  40.6% mood disorder –  15.4% anxiety disorder•  24.4% hospitalized for mental illness
  25. 25. 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)
  26. 26. Conclusions•  Characteristics to keep in mind when starting/continuing opioids: –  Hx of substance abuse? Tx? –  Daily smoker? –  Mental illness? –  Social support system?
  27. 27. Conclusions….(cont.)•  Things to discuss with patients: –  Dangers of using more often than prescribed –  Talk with family?
  28. 28. Study Objective and Design  Identify risk factors for death  People who died from prescription opioids  People who used prescription opioids  Compared populations
  29. 29. Data Sources: Decedents  Medical examiner records  Death certificates  Next-of-kin interviews
  30. 30. 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
  31. 31. 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
  32. 32. Comparison Group (N = 1,308)  Utah 2008 BRFSS  Used prescription opioid in prior 12 months  Utah residents  ≥18 years of age
  33. 33. Statistical Methods  Exposure prevalence (prevalence of characteristics)  Exposure prevalence ratios (EPR) as measure of association Decedent prevalence EPR = Comparison prevalence  95% Confidence intervals (CI)
  34. 34. 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)
  35. 35. Pain Type among Decedents No Acute pain pain 9% 8% Chronic pain 83%
  36. 36. 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)
  37. 37. Body Mass Index (BMI) BMI category Prevalence (%) EPR(Sex, BMI cat.) Decedents Comparison (95% CI) BMI <25 33.1 33.6 1.0 (0.9–1.1)BMI ≥25 but <30 28.1 35.6 0.8 (0.7–0.9) BMI ≥30 38.8 30.8 1.3 (1.1–1.4)Males, BMI ≥30 34.4 34.6 1.0 (0.8–1.2) Females, BMI ≥30 44.1 28.0 1.6 (1.3–1.8) BMI <25 33.1 33.6 1.0 (0.9–1.1)
  38. 38. Risk by Specific Opioid Prevalence (%) EPRCharacteristic Decedents Comparison (95% CI) 15.5 Methadone 28.1 1.8 (6.3–24.6) 5.7 Morphine 13.4 2.4 (3.5–7.9) 1.3 Oxycodone 37.9 28.4 (1.2–1.5) 0.4 Hydrocodone 25.3 69.6 (0.3–0.4)
  39. 39. Unemployed and Lived Alone Prevalence (%) EPRCharacteristic Decedents Comparison (95% CI) Unemployed 63.2 39.0 1.6 (1.5–1.8) Lived alone 23.2 6.7 3.5 (2.9–4.0)
  40. 40. 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
  41. 41. 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
  42. 42. 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%
  43. 43. Mental Illness Prevalence (%) EPRCharacteristic Decedents Comparison (95% CI) 2.2Depressed/FMD 30.3 13.5 (1.8–2.6)
  44. 44. 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)
  45. 45. 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)
  46. 46. 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
  47. 47. 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
  48. 48. 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
  49. 49. 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
  50. 50. 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
  51. 51. 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
  52. 52. Acknowledgments  Comparison data prepared by William Lanier, EIS  Utah Department of Health:   Todd Grey   Robert Rolfs   Jonathan Anderson   Kris Russell   Michael Friedrichs

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