1. 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

2. 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 , 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

4. 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)?

5. 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

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

7. 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?

8. 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

9. 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

10. 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

11. Price, Ilgen, & Bohnert, 2011 JSAT

12. Motives for Opioid Pain Medication Use

13. 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 presenting at an urban ED
33% in ED for an injury
4 modified COMM items to assess use

14. 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

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

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

17. Opioid Analgesics: Sales and Overdoses
Source: Medscape/CDC

18. 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?

19. Study 3: Prescription opioid overdoses among VHA patients
Case-cohort study,
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)

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

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

23. 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

24. 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

25. Thank you! Questions?
Amy S.B. Bohnert