william a. lanier, dvm, mph kristina russell, mph utah department of health risk factors for...

William A. Lanier, DVM, MPHKristina Russell, MPH

Utah Department of Health

Risk Factors for Prescription Opioid Death –

Utah, 2008–2009

Office of Surveillance, Epidemiology, and Laboratory Services

Scientific Education and Professional Development Program Office

Utah News Clippings about Prescription Drug Death

Deaths from Prescription Opioids Utah, 2000–2009

2000 2001 2002 2003 2004 2005 2006 2007 2008 20090

50

100

150

200

250

300

350

Year

Nu

mb

er

of

death

s

56

265

Prescription Opioid Use and Safety

Bind to opioid receptors in the central nervous system

Therapeutic Use Analgesia

Side Effects Respiratory depression Dependence

Causes of Prescription Opioid Death

Nonmedical use? Obtaining from nonprescription sources Using more than prescribed

Increase in opioids prescribed? Inherent risks of drugs Unsafe prescribing practices

Risk factors inadequately understood Lack of knowledge about decedents Lack of control group who used opioids

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

95% Confidence intervals (CI)

Decedent prevalence

Comparison prevalence

EPR =

Characteristics Compared and Denominators

CharacteristicDecedents

(N)Comparison

(N)

Medication source 222 1,300

Medication use 155 1,245

Chronic pain (obtained via prescription)

191 1,253

Education level 254 1,307

Smoking status 244 1,307

Marital status 254 1,276

Health insurance 243 1,307

Characteristic

Prevalence (%)

EPR (95% CI)Decedents

Comparison

Obtained via

prescription91.9 96.2

0.96 (0.94–0.97)

Obtained via other

source39.6 8.3

4.8 (3.6–6.0)

Used more than

prescribed52.9 3.2

16.5 (9.3–23.7)

Pain Medication Source and Use

Pain Type among Decedents

Acute pain8%

Chronic pain83%

No pain9%

Chronic Pain Comparison (Obtained via Prescription)

Chronic pain32%

Comparison (N = 1253)

Chronic pain94%

Decedents (N = 191)

EPR = 3.0 (95% CI = 2.7–

3.3)

Acute pain only

6%Acute

pain only 78%

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

Risk by Specific Opioid

Characteristic

Prevalence (%)

EPR (95% CI)Decedents

Comparison

Methadone 28.1 1.815.5

(6.3–24.6)

Morphine 13.4 2.45.7

(3.5–7.9)

Oxycodone 37.9 28.41.3

(1.2–1.5)

Hydrocodone 25.3 69.60.4

(0.3–0.4)

18–24 25–34 35–44 45–54 55–64 ≥650

5

10

15

20

25

30

35

Decedents

Comparison

Age category (years)

Pop

ula

tion

perc

en

tAge Category of

Decedents and Comparison Group

Age Category, Stratified by Sex

Characteristic

Prevalence (%)

EPR (95% CI)Decedents

Comparison

Male, 25–34 30.4 24.01.3 (1.0–

1.6)

Male, 35–44 24.4 20.41.2 (0.9–

1.5)

Male, 45–54 23.0 22.11.0 (0.8–

1.2)

Female, 25–34 21.8 24.80.9 (0.7–

1.0)

Female, 35–44 21.8 17.11.3 (1.0–

1.5)

Female, 45–54 37.0 16.12.3 (1.9–

2.7)

Education and Smoking

Characteristic

Prevalence (%)

EPR (95% CI)Decedents

Comparison

Did not graduate from

high school18.5 6.2

3.0 (2.0–3.9)

Smoked daily 54.5 9.75.6

(4.4–6.9)Smoked daily

(education-adjusted)

49.1 9.75.0

(4.0–6.1)

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

Characteristic

Prevalence (%)

EPR (95% CI)Decedents

Comparison

Divorced/Separated

34.6 9.43.7

(3.0–4.4)

Uninsured 29.2 12.52.3

(1.8–2.8)

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

Illicit Substance Use History (Lifetime)among Decedents (N = 251)

Number of Drugs

Number of

Decedents

Percentage of Decedents

(%)

Heroin 52 20.7

Cocaine 77 30.7

Any illicit substance

154 61.4

Illicit substance use treatment

129 51.4

Mental Illness

Characteristic

Prevalence (%)

EPR (95% CI)Decedents

Comparison

Depressed/FMD

30.3 13.52.2

(1.8–2.6)

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

For more information please contact Centers for Disease Control and Prevention1600 Clifton Road NE, Atlanta, GA 30333Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348E-mail: cdcinfo@cdc.gov Web: www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Office of Surveillance, Epidemiology, and Laboratory Services

Scientific Education and Professional Development Program Office

Utah Department of Health

CDC

Erin Johnson Jonathan Anderson

Diana Bensyl

Todd Grey Robert Rolfs Betsy Gunnels

Jacob Crook Michael Friedrichs

Len Paulozzi

Acknowledgments

Utah Department of Health Contact Information

William Lanier wlanier@utah.gov 801-538-6527

Erin Johnson erjohnso@utah.gov 801-538-6542

Kristina Russell krisrussell@utah.gov 801-538-9297

Extra Slides

Other Potential Risk Factors

Urban Military White Hispanic

Sex

Characteristic

Prevalence (%)

EPR (95% CI)Decedents

Comparison

Male 53.1 41.41.3

(1.2–1.4)

Unemployed and Lived Alone

Characteristic

Prevalence (%)

EPR (95% CI)Decedents

Comparison

Unemployed 63.2 39.01.6 (1.5–

1.8)

Lived alone 23.2 6.73.5 (2.9–

4.0)

Body Mass Index (BMI)

BMI category(Sex, BMI

cat.)

Prevalence (%)

EPR (95% CI)Decedents

Comparison

BMI <25 33.1 33.61.0 (0.9–

1.1)BMI ≥25 but

<30 28.1 35.60.8 (0.7–

0.9)

BMI ≥30 38.8 30.81.3 (1.1–

1.4)Males, BMI

≥30 34.4 34.61.0 (0.8–

1.2)Females, BMI

≥30 44.1 28.01.6 (1.3–

1.8)

BMI <25 33.1 33.61.0 (0.9–

1.1)

Numbers of Drugs as Decedent CODs (N = 254)

Number of Drugs

Number of

Decedents

Percentage of Decedents

(%)

1 56 22.0

2 56 22.0

3 76 29.9

4 44 17.3

≥5 22 8.7

Morphine or Heroin?

Heroin metabolizes to morphine Prescription morphine Heroin Unknown

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%