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William A. Lanier, DVM, MPH Kristina 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
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Utah News Clippings about Prescription Drug Death
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Deaths from Prescription Opioids Utah, 2000–2009 56 265
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Prescription Opioid Use and Safety Bind to opioid receptors in the central nervous system Therapeutic Use Analgesia Side Effects Respiratory depression Dependence
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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
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Study Objective and Design Identify risk factors for death People who died from prescription opioids People who used prescription opioids Compared populations
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Data Sources: Decedents Medical examiner records Death certificates Next-of-kin interviews
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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
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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
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Comparison Group (N = 1,308) Utah 2008 BRFSS Used prescription opioid in prior 12 months Utah residents ≥18 years of age
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Statistical Methods Exposure prevalence (prevalence of characteristics) Exposure prevalence ratios (EPR) as measure of association 95% Confidence intervals (CI) Decedent prevalence Comparison prevalence EPR =
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Characteristics Compared and Denominators CharacteristicDecedents (N)Comparison (N) Medication source2221,300 Medication use1551,245 Chronic pain (obtained via prescription) 1911,253 Education level2541,307 Smoking status2441,307 Marital status2541,276 Health insurance2431,307
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Characteristic Prevalence (%) EPR (95% CI) DecedentsComparison Obtained via prescription 91.996.2 0.96 (0.94–0.97) Obtained via other source 39.68.3 4.8 (3.6–6.0) Used more than prescribed 52.93.2 16.5 (9.3–23.7) Pain Medication Source and Use
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Pain Type among Decedents
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Chronic Pain Comparison (Obtained via Prescription) EPR = 3.0 (95% CI = 2.7–3.3) Acute pain only 6% Acute pain only 78%
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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
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Risk by Specific Opioid Characteristic Prevalence (%) EPR (95% CI) DecedentsComparison Methadone28.11.8 15.5 (6.3–24.6) Morphine13.42.4 5.7 (3.5–7.9) Oxycodone37.928.4 1.3 (1.2–1.5) Hydrocodone25.369.6 0.4 (0.3–0.4)
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Age Category of Decedents and Comparison Group
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Age Category, Stratified by Sex Characteristic Prevalence (%) EPR (95% CI) DecedentsComparison Male, 25–3430.424.01.3 (1.0–1.6) Male, 35–4424.420.41.2 (0.9–1.5) Male, 45–5423.022.11.0 (0.8–1.2) Female, 25–3421.824.80.9 (0.7–1.0) Female, 35–4421.817.11.3 (1.0–1.5) Female, 45–5437.016.12.3 (1.9–2.7)
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Education and Smoking Characteristic Prevalence (%) EPR (95% CI) DecedentsComparison Did not graduate from high school 18.56.2 3.0 (2.0–3.9) Smoked daily54.59.7 5.6 (4.4–6.9) Smoked daily (education- adjusted) 49.19.7 5.0 (4.0–6.1)
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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
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Marital Status and Health Insurance Characteristic Prevalence (%) EPR (95% CI) DecedentsComparison Divorced/ Separated 34.69.4 3.7 (3.0–4.4) Uninsured 29.212.5 2.3 (1.8–2.8)
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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
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Illicit Substance Use History (Lifetime) among Decedents (N = 251) Number of Drugs Number of Decedents Percentage of Decedents (%) Heroin5220.7 Cocaine7730.7 Any illicit substance 15461.4 Illicit substance use treatment 12951.4
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Mental Illness Characteristic Prevalence (%) EPR (95% CI) DecedentsComparison Depressed/FMD30.313.5 2.2 (1.8–2.6)
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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
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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
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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
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For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-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 JohnsonJonathan AndersonDiana Bensyl Todd GreyRobert RolfsBetsy Gunnels Jacob CrookMichael FriedrichsLen Paulozzi Acknowledgments
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Utah Department of Health Contact Information William Lanier wlanier@utah.gov wlanier@utah.gov 801-538-6527 Erin Johnson erjohnso@utah.gov erjohnso@utah.gov 801-538-6542 Kristina Russell krisrussell@utah.gov krisrussell@utah.gov 801-538-9297
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Extra Slides
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Other Potential Risk Factors Urban Military White Hispanic
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Sex Characteristic Prevalence (%) EPR (95% CI) DecedentsComparison Male53.141.4 1.3 (1.2–1.4)
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Unemployed and Lived Alone Characteristic Prevalence (%) EPR (95% CI) DecedentsComparison Unemployed 63.239.01.6 (1.5–1.8) Lived alone 23.26.73.5 (2.9–4.0)
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Body Mass Index (BMI) BMI category (Sex, BMI cat.) Prevalence (%) EPR (95% CI) DecedentsComparison BMI <25 33.133.61.0 (0.9–1.1) BMI ≥25 but <30 28.135.60.8 (0.7–0.9) BMI ≥30 38.830.81.3 (1.1–1.4) Males, BMI ≥30 34.434.61.0 (0.8–1.2) Females, BMI ≥30 44.128.01.6 (1.3–1.8) BMI <25 33.133.61.0 (0.9–1.1)
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Numbers of Drugs as Decedent CODs (N = 254) Number of Drugs Number of Decedents Percentage of Decedents (%) 15622.0 25622.0 37629.9 44417.3 ≥5 228.7
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Morphine or Heroin? Heroin metabolizes to morphine Prescription morphine Heroin Unknown
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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%
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