1. 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

2. Utah News Clippings about Prescription Drug Death

3. Deaths from Prescription Opioids Utah, 2000–2009 56 265

4. Prescription Opioid Use and Safety  Bind to opioid receptors in the central nervous system  Therapeutic Use  Analgesia  Side Effects  Respiratory depression  Dependence

5. 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

6. Study Objective and Design  Identify risk factors for death  People who died from prescription opioids  People who used prescription opioids  Compared populations

7. Data Sources: Decedents  Medical examiner records  Death certificates  Next-of-kin interviews

8. 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

9. 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

10. Comparison Group (N = 1,308)  Utah 2008 BRFSS  Used prescription opioid in prior 12 months  Utah residents  ≥18 years of age

11. Statistical Methods  Exposure prevalence (prevalence of characteristics)  Exposure prevalence ratios (EPR) as measure of association  95% Confidence intervals (CI) Decedent prevalence Comparison prevalence EPR =

12. 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

13. 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

14. Pain Type among Decedents

15. Chronic Pain Comparison (Obtained via Prescription) EPR = 3.0 (95% CI = 2.7–3.3) Acute pain only 6% Acute pain only 78%

16. 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

17. 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)

18. Age Category of Decedents and Comparison Group

19. 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)

20. 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)

21. 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

22. 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)

23. 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

24. 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

25. Mental Illness Characteristic Prevalence (%) EPR (95% CI) DecedentsComparison Depressed/FMD30.313.5 2.2 (1.8–2.6)

26. 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

27. 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

28. 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

29. 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

30. 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

31. Extra Slides

32. Other Potential Risk Factors  Urban  Military  White  Hispanic

33. Sex Characteristic Prevalence (%) EPR (95% CI) DecedentsComparison Male53.141.4 1.3 (1.2–1.4)

34. 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)

35. 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)

36. 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

37. Morphine or Heroin?  Heroin metabolizes to morphine  Prescription morphine  Heroin  Unknown

38. 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%