William A. Lanier, DVM, MPHKristina Russell, MPH

Utah Department of Health

Risk Factors for Prescription Opioid Death –

Utah, 2008–2009

Office of Surveillance, Epidemiology, and Laboratory ServicesScientific Education and Professional Development Program Office

Utah News Clippings about Prescription Drug Death

Deaths from Prescription Opioids Utah, 2000–2009

2000 2001 2002 2003 2004 2005 2006 2007 2008 20090

50

100

150

200

250

300

350

Year

Num

ber

of d

eath

s

56

265

Prescription Opioid Use and Safety Bind to opioid receptors in the central

nervous system Therapeutic Use

Analgesia

Side Effects Respiratory depression Dependence

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

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

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

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

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

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

Statistical Methods Exposure prevalence (prevalence of

characteristics)

Exposure prevalence ratios (EPR) as measure of association

95% Confidence intervals (CI)

Decedent prevalence

Comparison prevalence

EPR =

Characteristics Compared and Denominators

CharacteristicDecedents

(N)Comparison

(N)Medication source 222 1,300

Medication use 155 1,245Chronic pain

(obtained via prescription)

191 1,253

Education level 254 1,307

Smoking status 244 1,307

Marital status 254 1,276

Health insurance 243 1,307

Characteristic

Prevalence (%)EPR

(95% CI)DecedentsCompariso

n

Obtained via

prescription91.9 96.2

0.96 (0.94–0.97)

Obtained via other

source39.6 8.3 4.8

(3.6–6.0)

Used more than

prescribed52.9 3.2 16.5

(9.3–23.7)

Pain Medication Source and Use

Pain Type among Decedents Acute pain

8%

Chronic pain83%

No pain9%

Chronic Pain Comparison (Obtained via Prescription)

Chronic pain32%

Comparison (N = 1253)

Chronic pain94%

Decedents (N = 191)

EPR = 3.0 (95% CI = 2.7–

3.3)

Acute pain only

6% Acute pain only

78%

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

Risk by Specific Opioid

Characteristic

Prevalence (%)EPR

(95% CI)DecedentsCompariso

n

Methadone 28.1 1.815.5

(6.3–24.6)

Morphine 13.4 2.45.7

(3.5–7.9)

Oxycodone 37.9 28.41.3

(1.2–1.5)

Hydrocodone 25.3 69.60.4

(0.3–0.4)

18–24 25–34 35–44 45–54 55–64 ≥650

5

10

15

20

25

30

35

Decedents

Comparison

Age category (years)

Popu

latio

n pe

rcen

tAge Category of

Decedents and Comparison Group

Age Category, Stratified by Sex

Characteristic

Prevalence (%)EPR

(95% CI)DecedentsCompariso

nMale, 25–34 30.4 24.0 1.3 (1.0–

1.6)Male, 35–44 24.4 20.4 1.2 (0.9–

1.5)Male, 45–54 23.0 22.1 1.0 (0.8–

1.2)Female, 25–34 21.8 24.8 0.9 (0.7–

1.0)Female, 35–44 21.8 17.1 1.3 (1.0–

1.5)Female, 45–54 37.0 16.1 2.3 (1.9–

2.7)

Education and Smoking

Characteristic

Prevalence (%)EPR

(95% CI)DecedentsCompariso

n

Did not graduate from

high school18.5 6.2 3.0

(2.0–3.9)

Smoked daily 54.5 9.7 5.6 (4.4–6.9)

Smoked daily (education-

adjusted)49.1 9.7 5.0

(4.0–6.1)

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

Marital Status and Health Insurance

Characteristic

Prevalence (%)EPR

(95% CI)DecedentsCompariso

n

Divorced/Separated 34.6 9.4 3.7

(3.0–4.4)

Uninsured 29.2 12.5 2.3 (1.8–2.8)

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

Illicit Substance Use History (Lifetime)among Decedents (N = 251)

Number of Drugs

Number of

Decedents

Percentage of Decedents

(%)

Heroin 52 20.7

Cocaine 77 30.7

Any illicit substance 154 61.4

Illicit substance use treatment 129 51.4

Mental Illness

Characteristic

Prevalence (%)EPR

(95% CI)DecedentsCompariso

nDepressed/

FMD 30.3 13.5 2.2(1.8–2.6)

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

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

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

For more information please contact Centers for Disease Control and Prevention1600 Clifton Road NE, Atlanta, GA 30333Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348E-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 ServicesScientific Education and Professional Development Program Office

Utah Department of Health

CDC

Erin Johnson Jonathan Anderson

Diana Bensyl

Todd Grey Robert Rolfs Betsy GunnelsJacob Crook Michael

FriedrichsLen Paulozzi

Acknowledgments

Utah Department of Health Contact Information

William Lanier wlanier@utah.gov 801-538-6527

Erin Johnson erjohnso@utah.gov 801-538-6542

Kristina Russell krisrussell@utah.gov 801-538-9297

Extra Slides

Other Potential Risk Factors Urban Military White Hispanic

Sex

Characteristic

Prevalence (%)EPR

(95% CI)DecedentsCompariso

n

Male 53.1 41.4 1.3(1.2–1.4)

Unemployed and Lived Alone

Characteristic

Prevalence (%)EPR

(95% CI)DecedentsCompariso

n

Unemployed 63.2 39.01.6 (1.5–

1.8)

Lived alone 23.2 6.73.5 (2.9–

4.0)

Body Mass Index (BMI)

BMI category(Sex, BMI

cat.)

Prevalence (%)

EPR (95% CI)Decedents

Comparison

BMI <25 33.1 33.61.0 (0.9–

1.1)BMI ≥25 but

<30 28.1 35.60.8 (0.7–

0.9)

BMI ≥30 38.8 30.81.3 (1.1–

1.4)Males, BMI

≥30 34.4 34.61.0 (0.8–

1.2)Females, BMI

≥30 44.1 28.01.6 (1.3–

1.8)

BMI <25 33.1 33.61.0 (0.9–

1.1)

Numbers of Drugs as Decedent CODs (N = 254)

Number of Drugs

Number of

Decedents

Percentage of Decedents

(%)

1 56 22.0

2 56 22.0

3 76 29.9

4 44 17.3≥5 22 8.7

Morphine or Heroin? Heroin metabolizes to morphine Prescription morphine Heroin Unknown

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%