erin johnson

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 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.

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 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.

Bear Trap

Number of Unintentional Prescription Opioid Drug Overdose Cases by Year: Utah,

2000-2010

Utah Medical Examiner Data

What we knew

•  ME data: – Sex – BMI – Age – Drugs involved

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?

What we did •  Next-of-kin interviews

•  Worked under Medical Examiner – Determine manner of death

•  Interviews over telephone

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

Study Population Flowchart 432

drug deaths

268 (62%) prescription opioid COD

Study Population Flowchart

233 (87%) prescription opioid COD,

no illicit drug COD

432 drug deaths


Study Population Flowchart

254 (91%) prescription opioid COD with completed interview

432 drug deaths


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

Demographics

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

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

Two Face

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

  95% Confidence intervals (CI)

Decedent prevalence

Comparison prevalence EPR =

Characteristic Prevalence (%) EPR

(95% CI) Decedents Comparison

Obtained via prescription 80.3 96.2 0.8

(0.8–0.9)

Obtained via other source 35.8 8.3 4.3

(3.2–5.4)

Used more than prescribed 52.9 3.2 16.5

(9.3–23.7)

Pain Medication Source and Use

Pain Type among Decedents

Acute pain 8%

Chronic pain 83%

No pain 9%

Chronic Pain Comparison (Obtained via Prescription)

Chronic pain 32%

Comparison (N = 1253)

Chronic pain 94%

Decedents (N = 191)

EPR = 3.0 (95% CI = 2.7–3.3)

Acute pain only

6% Acute pain only

78%

Body Mass Index (BMI)

BMI category (Sex, BMI cat.)

Prevalence (%) EPR (95% CI) Decedents Comparison

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)

Risk by Specific Opioid



Methadone 28.1 1.8 15.5

(6.3–24.6)

Morphine 13.4 2.4 5.7

(3.5–7.9)

Oxycodone 37.9 28.4 1.3

(1.2–1.5)

Hydrocodone 25.3 69.6 0.4

(0.3–0.4)

Unemployed and Lived Alone



Unemployed 63.2 39.0 1.6 (1.5–1.8)

Lived alone 23.2 6.7 3.5 (2.9–4.0)

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

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

Type 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

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%

Mental Illness



Depressed/FMD 30.3 13.5 2.2 (1.8–2.6)

Education and Smoking



Did not graduate from high school 18.5 6.2 3.0

(2.0–3.9)

Smoked daily 54.5 9.7 5.6 (4.4–6.9)

Smoked daily (education-

adjusted) 49.1 9.7 5.0

(4.0–6.1)

Marital Status and Health Insurance



Divorced/ Separated

34.6 9.4 3.7 (3.0–4.4)

Uninsured 29.2 12.5 2.3 (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

erin johnson

Health & Medicine