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

1. What Every Clinician
Needs to Know
About Overdoses
April 10-12, 2012
Walt Disney World Swan Resort

2. Learning Objectives:
1. Describe the characteristics and risk factors
that may predispose patients to an overdose.
2. State the value of Poison Control Center
data in formulating strategies to reduce
prescription drug diversion health care
associated problems.

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. Common Characteristics Among
Rx Opioid Overdose Decedents
Erin Johnson, MPH,
Utah Department of Health

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. Utah News Clippings about Prescription Drug Death

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. To prevent and reduce the
misuse and abuse of
prescription pain medications in
Utah by providing information
and strategies regarding safe
use, safe storage, and safe
disposal of these potentially
dangerous drugs.

9. Bear Trap

10. Number of Unintentional Prescription
Opioid Drug Overdose Cases by Year: Utah,
2000-2010
Utah Medical Examiner Data

11. What we knew
• ME data:
– Sex
– BMI
– Age
– Drugs involved

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. What we did
• Next-of-kin interviews
• Worked under Medical Examiner
– Determine manner of death
• Interviews over telephone

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. Study Population Flowchart
432
drug deaths
268 (62%)
prescription opioid COD

16. Study Population Flowchart
432
drug deaths
278 (64%)
prescription opioid COD
233 (87%)
prescription opioid COD,
no illicit drug COD

17. Study Population Flowchart
432
drug deaths
278 (64%)
prescription opioid COD
254 (91%)
prescription opioid COD
with completed interview

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. Demographics
• 53.2% male
• 79.1% between ages 25-54
• 66.9% overweight (BMI>25)

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. 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. Two Face

24. 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

25. Mental Health
• 54.3% diagnosed with mental illness (in
lifetime)
– 40.6% mood disorder
– 15.4% anxiety disorder
• 24.4% hospitalized for mental illness

26. 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)

27. Conclusions
• Characteristics to keep in mind when
starting/continuing opioids:
– Hx of substance abuse? Tx?
– Daily smoker?
– Mental illness?
– Social support system?

28. Conclusions….(cont.)
• Things to discuss with patients:
– Dangers of using more often than
prescribed
– Talk with family?

29. Study Objective and Design
 Identify risk factors for death
 People who died from prescription opioids
 People who used prescription opioids
 Compared populations

30. Data Sources: Decedents
 Medical examiner records
 Death certificates
 Next-of-kin interviews

31. 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

32. 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

33. Comparison Group (N = 1,308)
 Utah 2008 BRFSS
 Used prescription opioid in prior 12 months
 Utah residents
 ≥18 years of age

34. Statistical Methods
 Exposure prevalence (prevalence of characteristics)
 Exposure prevalence ratios (EPR) as measure of
association
Decedent prevalence
EPR =
Comparison prevalence
 95% Confidence intervals (CI)

35. Pain Medication Source and Use
Prevalence (%) EPR
Characteristic Decedents Comparison (95% CI)
Obtained 0.8
80.3 96.2
via prescription (0.8–0.9)
Obtained 4.3
35.8 8.3
via other source (3.2–5.4)
Used more than 16.5
52.9 3.2
prescribed (9.3–23.7)

36. Pain Type among Decedents
No Acute
pain pain
9% 8%
Chronic
pain
83%

37. Chronic Pain Comparison
(Obtained via Prescription)
Decedents (N = 191) Comparison (N = 1253)
Acute
pain only
Acute
6%
pain only
78%
Chronic Chronic
pain pain
94% 32%
EPR = 3.0
(95% CI = 2.7–3.3)

38. 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)

39. Risk by Specific Opioid
Prevalence (%) EPR
Characteristic 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)

40. Unemployed and Lived Alone
Prevalence (%) EPR
Characteristic 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)

41. Numbers of Drugs
as Decedent CODs (N = 254)
Number of Percentage of
Number of Drugs Decedents Decedents (%)
1 56 22.0
2 56 22.0
3 76 29.9
4 44 17.3
≥5 22 8.7

42. Illicit Substance Use History (Lifetime)
among Decedents (N = 251)
Number of Percentage of
Type of Drugs Decedents Decedents (%)
Heroin 52 20.7
Cocaine 77 30.7
Any illicit
154 61.4
substance
Illicit substance
129 51.4
use treatment

44. 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%

45. Mental Illness
Prevalence (%) EPR
Characteristic Decedents Comparison (95% CI)
2.2
Depressed/FMD 30.3 13.5
(1.8–2.6)

46. Education and Smoking
Prevalence (%) EPR
Characteristic Decedents Comparison (95% CI)
Did not graduate 3.0
18.5 6.2
from 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)

47. Marital Status and Health Insurance
Prevalence (%) EPR
Characteristic 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)

48. 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

49. 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

50. 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

51. 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

52. 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

53. 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

55. Acknowledgments
 Comparison data prepared by William Lanier, EIS
 Utah Department of Health:
 Todd Grey
 Robert Rolfs
 Jonathan Anderson
 Kris Russell
 Michael Friedrichs