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What Every Clinician Needs to Know About OverdosesNational Rx Drug Abuse Summit 4-10-12
Citation preview
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
278 (64%) prescription opioid COD
Study Population Flowchart
254 (91%) prescription opioid COD with completed interview
432 drug deaths
278 (64%) prescription opioid COD
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
Characteristic Prevalence (%) EPR
(95% CI) Decedents Comparison
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
Characteristic Prevalence (%) EPR
(95% CI) Decedents Comparison
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
Characteristic Prevalence (%) EPR
(95% CI) Decedents Comparison
Depressed/FMD 30.3 13.5 2.2 (1.8–2.6)
Education and Smoking
Characteristic Prevalence (%) EPR
(95% CI) Decedents Comparison
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
Characteristic Prevalence (%) EPR
(95% CI) Decedents Comparison
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