william a. lanier, dvm, mph kristina russell, mph utah department of health risk factors for...
TRANSCRIPT
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: [email protected] 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 [email protected] 801-538-6527
Erin Johnson [email protected] 801-538-6542
Kristina Russell [email protected] 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%