Prescription Opioids: Extramedical Use and Overdose Amy S.B. Bohnert, Ph.D. VA National Serious Mental Illness Treatment Resource & Evaluation Center VA Ann Arbor HSR&D Center of Excellence, Center for Clinical Management Research University of Michigan Medical School, Department of Psychiatry

No conflicts of interest to report. Acknowledgements Supported by funding from Veteran Health Administration, Office of Mental Health Services and VA HSR&D grant CDA-09-204, and the University of Michigan Department of Psychiatry and Injury Center. No conflicts of interest to report. Collaborators: Matt Bair Frederic Blow Anna Eisenberg Dara Ganoczy Rose Ignacio Mark Ilgen John McCarthy Amanda Price Marcia Valenstein

Prescription Opioids: Research Goals What are groups that have a high prevalence of use? Where can they be found? How can we better measure prescription opioid use that is not part of medical care? How can we reduce the harms associated with prescription opioids (OVERDOSE)?

Use of Prescription Opioids in the U.S. Prescription Opioids: pain medications that contain opioids (naturally occurring or synthetic) and require a prescription in the U.S., including codeine, percocet, fentanyl etc. Pain Treatment Extramedical Use Non-Medical Use

Non-Medical Prescription Opioid Use in the U.S. Source: SAMSHA

Research Goals 1 + 2 What are groups that have a high prevalence of use? Where can they be found? How can we better measure prescription opioid use that is not part of medical care?

Study 1: Extramedical use among patients at a residential addictions treatment program Residential Treatment Unit- addictions treatment in which patients live together at the treatment center Use is likely to be common- allows us to consider measurement issues Cross-sectional survey, n = 351 Participants largely in treatment for alcohol or cocaine use-related problems

Opioid Use Measurement (past 30 days) 1 item from the Addiction Severity Index (ASI) Days used non-prescribed opiates/analgesics 6 items from the Current Opiate Misuse Measure (COMM) Scale: Never – Rarely – Sometimes – Often – Very Often Taking medication belonging to someone else Going to someone other than the prescribing physician Taking more than prescribed Taking differently than prescribed Using for symptoms other than pain (e.g., improve mood, help sleep, relieve stress) Borrowed pain medications

Study 1 Results: Past 30 Day Extramedical Use COMM: 68% (n = 238) endorsed at least one of six items ASI: 25% (n = 89) reported at least one day of use

Price, Ilgen, & Bohnert, 2011 JSAT

Motives for Opioid Pain Medication Use

Study 2: Extramedical use among emergency department (ED) patients EDs have an elevated prevalence of drug use, are a location of brief intervention trials ED-based study of prescription opioid use Survey of 1,027 patients age 18-60 presenting at an urban ED 33% in ED for an injury 4 modified COMM items to assess use

Study 2: Results Past 3 month opioid pain medication use (including medical use): 49.5% (n = 508) Among those with any use, 50.6% (n = 257) reported extra-medical use (~25% sample) Source non-medical: 47.1% More than prescribed: 61.1% For reasons other than pain relief: 35.0% Some else’s Rx: 40.9% Of those with extramedical use, 20.2% had a prior non-fatal overdose

Research Goal 3 How can we reduce the harms associated with prescription opioids? Dramatic increase in unintentional opioid overdoses

Fatal Accidental Overdoses are Increasing in the US Bohnert, Fudalej, & Ilgen, 2010, Pub Health Rep

Opioid Analgesics: Sales and Overdoses Source: Medscape/CDC

Causes of Prescription Opioid Overdose in the U.S. Extra-Medical Use Pain Treatment Strategies: -Prescription monitoring systems -Prescribing practices -Patient and caregiver education Strategies: -Diversion reduction -Universal prevention to reduce initiation -Harm and use reduction -Naloxone?

Study 3: Prescription opioid overdoses among VHA patients Case-cohort study, 2004-2008 1,136 prescription opioid overdose decedents (of 5,719,542 patients) 750 (66%) had been prescribed opioids Random Sample = 154,684 Data Sources: National Death Index, VHA Patient Records Focus on prescribing regimen (dose + schedule)

From Bohnert, Bair, Valenstein et al., 2011 JAMA

From Bohnert, Bair, Valenstein et al., 2011 JAMA

Conclusions Non-medical/Extra-medical prescription opioid use is common among some specific sub-populations of adults Prescription opioid overdose is a pressing public health concern A number of different types of interventions that target medical use and non-medical use of prescription opioids are needed

Future Directions What about other high-risk sub-groups? Psychiatric patients Developing prescription opioid overdose prevention strategies Extramedical Use Injury Center Pilot Medical Use project on VA opioid prescribing

Thank you! Questions? Amy S.B. Bohnert amybohne@med.umich.edu