Prescription Drug Poisoning: No Longer A Silent Epidemic

Christy Porucznik, PhD MSPH

Utah Health Status Update:August 2007

Poisonings surpass motor vehicle crashes as Utah’s leading cause of injury death.

In 2003, rate of unintentional and undetermined intent poisoning deaths, 13.9 per 100,000, surpassed that for motor vehicle crash, 13.2 per 100,000.

The increase has continued and the gap is widening.

http://health.utah.gov/opha/publications/hsu/07Aug_UninsKids.pdf

National Status, 2014

41,340 deaths

16,917 deathsNearly 4x increase since 1999

Death Certificates as a Data Source

• Underlying causes of death classified using ICD-10 and selected by the drug poisoning codes

• X40: Accidental poisoning by and exposure to non-opioid analgesics, antipyretics and antirheumatics

• X42: Accidental poisoning by and exposure to narcotics and psychodysleptics [hallucinogens], not elsewhere classified

• X60: Intentional self-poisoning by and exposure to nonopioid analgesics, antipyretics and antirheumatics

US Death Certificates: Consider Age

• Specific drugs noted in the T codes based upon autopsy findings– T40.2: natural and semisynthetic opioid analgesic– T40.3: methadone– T40.4: synthetic opioid analgesic, excluding

methadone– T42.4: benzodiazepines

• In 2011, 25% of drug-poisoning deaths did not include any specific drugs– T50.9: unspecified, drug-related

US Death Certificates: Categories of Analgesics

Utah Medical Examiner Database

US Death Certificates: Benzodiazepines and Opioids

2004: Where we began…• Medical Examiner noticed more deaths caused

by prescribable drugs, asked epidemiologist to take a look at the data

• Using Medical Examiner data– Centralized, statewide medical examiner

• Reviewed all drug poisoning deaths between 1991 and 2003– Categorized by type of drug involved

Number of Drug Poisoning Deaths by Drug Category and Year — Utah 1991-2003

0

50

100

150

200

250

1991 1993 1995 1997 1999 2001 2003Year

Num

ber o

f Dru

g O

verd

ose

Dea

ths Illicit Drugs Only

Non-Illicit DrugsOnlyBoth Illicit and Non-Illicit Drugs

Increase in Number of Methadone-Related Deaths

• Office of the Medical Examiner case files for methadone-related deaths

• Year 2000 on the left, 2004 on the right

Questions• Was this a patient

safety problem?

• Was this a law enforcement problem?

• Was it both?

PMP: Utah Controlled Substances Database (CSD)

• Maintained by Division of Occupational and Professional Licensing (Commerce)

• Registry of all prescriptions for Schedule II-V drugs dispensed in Utah and by Utah providers.

• Worked with the legislature to change the law and rules so that data could be used for research by the Department of Health

Using administrative data for research

• The CSD was never intended for research• The first users to try and analyze it in

aggregate• Much data cleaning• Very large dataset, long computer runtime • Lacks a unique patient identifier, so we used a

combination deterministic-probabilistic algorithm to create individual patient histories

First Linking of ME to PMP (2006)

• 47% had an active opioid Rx at time of death– 57% filled within 30 days of death, – 63% within 90 days of death, and 75% within 365

days of death. • No evidence of a filled opioid prescription

from 1999 through the date of death for only 15% of these decedents

• 43% had an active Rx for every drug identified on toxicology at time of death

Prescription Pain Medication:What you need to know

Credit for these slides to Erin Johnson, MPH

www.useonlyasdirected.org www.health.utah.gov/prescription

HB 137: Legislative ChargeJuly 2007-2009

• Research– Causes, risk factors, solutions

• Create Guidelines• Educate

– Health Care Providers– Patients– Insurers– General Public

Mean Annual ED Visits Per Patient by Year and Patient Type

Enhanced ME Investigation• Interviews were conducted for Utah residents

ages 12+ who died from drug-related causes between October 26, 2008-October 25, 2009.

• 432 potential cases (20.7% of OME cases for the year), 385 completed interviews (90%)

• Majority (64%) involved at least one opioid pain drug– 38/278 opioid pain drug + illicit drug

• 83% of the decedents had chronic pain

• 87.4% of decedents had taken prescription pain medication within 1 year of deathReporting all sources– 91.8% from healthcare provider– 24% free from a friend or relative– 18.2% stolen– 16.4% purchased from a friend or relative– 11.6% purchased from a drug dealer

• Among decedents taking medication prescribed by a healthcare provider– 52.9% took more than prescribed– 42.4% had visited multiple doctors to get

medications– 29.8% used pain medications for other reasons

• Recreational use, 48.4%• Self-medication for depression, 25.0%; anxiety, 15.6%;

or sleep, 4.6%

Social Characteristics

Decedents• In the 2 months prior to death

– 36.8% employed– 59.8% had financial problems

• 70.8% had health insurance at the time of death

• 47.8% had a physical disability

Comparison Population• Utah: 61.4% employed• U.S. males & females

– 82.0% & 73.0% employed• 14.3% U.S. adults in poverty• 83.3% U.S. adults insured

• 32.0% U.S. adults complex activity limitation

BRFSS: Medically Unsupervised Use of Prescription Pain Drugs

• 12 questions added to 2008 BRFSS• 5,330 respondents (ages 18+)• 20.8% prescribed opioid pain drug in previous

year– 3.2% used own Rx more frequently or in higher

doses than prescribed– 72% had leftover medication

• 71% kept the leftover medication

BRFSS Results• 1.8% of respondents reported using

prescription opioids not prescribed to them• Corresponds to 34,637 Utah adults• 97% received it from a friend or relative

– 85.2% free or as a gift– 9.8% took it without the person’s knowledge

Education: Patients & General Public

• Media Campaign Jan 2008-June 2009– Public Opinion Survey– Collateral materials– Prescription Awareness Week (end of October)– Contracted with Vanguard Media

Initial Research for Media Campaign• 3 Focus Groups

• Statewide telephone survey– Key Findings (among 23 of 29 counties)

• Doctors and pharmacies are primary sources of information about medication

• Most people have NOT seen information about prescription pain medications at doctors offices or pharmacies

Television

Radio

Website

Collateral materials

Print advertisements

Community events and displays

Coverage in the news media

Tracking hits to the website

Media Campaign Post Survey Results• Research Results

– 48% of Utah residents recall seeing the commercial• Majority (62%) saw it more than 5 times

– 34% said media messages made them a “Great Deal” more aware (53% at least somewhat)

– 35% had seen information at doctor’s office– 32% had seen info at pharmacy

Utah Clinical Guidelines on Prescribing Opioids

• Based on 7 evidence-based guidelines • Utah consensus product• Mandated by legislature• Accompanied by implementation tools

Guidelines

• Aimed at providers who prescribe opioids for the treatment of pain

• Summary and Full versions available• Available for free by request or online at:

Useonlyasdirected.org

Provider Education

• 30 small group trainings– 6-10 doctors– Required homework – Evaluation of behavior change– Follow up surveys (Up to 20 CME credits)

• 10 large group presentations– 5 CME’s

• Mailings/Articles

Continuing Research• Survey providers, have they changed?

• Using the CSD data to examine changes in prescribing– Evaluate impact of Utah Clinical Guidelines on

Prescribing Opioids

Provider Survey• Report that they lack

– Sufficient training to feel confident prescribing opioids

– Referral resources• Use screening tools that are incorporated into

the electronic medical record, not external tools

• Do not enjoy treating patients with chronic, non-malignant pain

Annual Number of Unique Opioid Patients in the CSD

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011580000

600000

620000

640000

660000

680000

700000

720000

740000

Annual Unique Methadone Patients in the CSD

2002 2003 2004 2005 2006 2007 2008 2009 2010 20110

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

Rx Opioid-Related Deaths Investigated by the Medical Examiner, Utah 2000-2014

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 20140

50

100

150

200

250

300

350

UDOH received funding forprescription pain medicationeducation and research

2014 data are preliminary

Funding eliminated

• Mandates that providers must register with online query system in order to renew their controlled substance prescribing license– Does not require providers to use the system

• Passed in March• Licenses expire in June• Must register by September 30

Utah HB 28 (2010)

1. Did the implementation of HB28 result in increased provider utilization of the Controlled Substances Database (CSD) online system?

Can study this using the log file associated with the online system

first use of these data!

Research Questions

System use has increased

H.B. 28 passed, March 2010

H.B. 28 takes effect, September 2010

Whose fault is this anyway?

• Pain specialists point fingers to primary care• Primary care points right back

• Primary care writes majority of prescriptions• Specialties, including pain medicine,

associated with more fatalities than we would expect based on their prescribing

Physician Specialty and ADE

• Used our file which links the CSD to the medical examiner data

• Attached physician specialty to each rx using information from the NPI

• Deaths were assigned to every provider who had written a prescription for the decedent which was active at the time of death

Evaluating Impact: Utah Clinical Guidelines on Prescribing Opioids• Not a simple task• Classified individual patients by user type

– Acute– Intermittent– Chronic

• Created indicator flags for guideline violations based on data available in CSD

Utah CSD: Methadone Initiation

ACUTE CHRONIC INTERMITTENT PALLIATIVE ALL USERS0%

10%

20%

30%

40%

50%

60%

Proportion of Any Methadone Flagsby User Type and Time Period

Prop

ortio

n

Utah CSD: Dual Use of Long Acting Opioids

ACUTE CHRONIC INTERMITTENT PALLIATIVE ALL USERS0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

Proportion of Dual Use of Long-acting Opioidsby User Type and Time Period

Prop

ortio

n

Linked Utah CSD and ED: Opioid-Related ED Visits Among Patients

ACUTE CHRONIC INTERMITTENT PALLIATIVE ALL USERS0.0%

0.2%

0.4%

0.6%

0.8%

1.0%

1.2%

Proportion of Opioid Related ED Visitsby User Type and Time Period

Prop

ortio

n

PMP: Lessons Learned• Helpful to have unique identifier to create

individual prescription histories (we don’t have this)

• Ongoing data quality verification important to maintain integrity and utility of data

• Providers need to know that the data are timely and accurate

What do we wish for?• Indicator variable for veterinary prescriptions• Physician specialty in the PMP• Information about group practices in the PMP

– and mid-levels associated with providers• Ability to link PMP with medical records

– Diagnosis– Other, non CS prescriptions

The future?• Bi-directional communication for providers

with the PMP– What happens when they query?– Ability for provider to insert a red flag onto a

patient record in the PMP• More use of PMP for systematic monitoring of

community-level indicators• Aberration detection in real time

Questions?

Christy Porucznik, PhD MSPHchristy.porucznik@utah.edu