The Role of Clinicians in Addressing the Opioid Overdose Epidemic - Slides

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Risk Factors for Opioid Overdose & Awareness of Overdose Risk among Veterans Prescribed Chronic Opioids for Addiction or Pain

Background

Rising overdose fatalities among US veterans suggest veterans taking prescription opioids may be at risk for overdose. However, it is unclear whether veterans prescribed chronic opioids are aware of this risk.

Objectives

The objective of this study was to identify risk factors and determine awareness of risk for opioid overdose in veterans treated with opioids for chronic pain, using veterans treated with methadone or buprenorphine for opioid use disorder as a high-risk comparator group.

Methods

Ninety veterans on chronic opioid medication for either opioid use disorder or pain management completed a questionnaire assessing risk factors, knowledge, and self-estimate of risk for overdose.

Results

Nearly all veterans in both groups had multiple overdose risk factors although individuals in the pain management group had on average a significantly lower total number of risk factors than did individuals in the opioid use disorder group (5.9 v. 8.5, p<0.0001). On average, participants treated for pain management scored slightly but significantly lower on knowledge of opioid overdose risk factors (12.1 v. 13.5, p<0.01). About 70% of participants, regardless of group, believed their overdose risk was below that of the average American adult. There was no significant relationship between self-estimate of overdose risk and either number or knowledge of opioid overdose risk factors.

Discussion

Our results suggest that veterans in both groups underestimated their risk for opioid overdose. Expansion of overdose education to include individuals on chronic opioids for pain management and a shift in educational approaches to overdose prevention may be indicated.

Below:  Participant estimate of risk for overdose on opioids in the next year, using visual analog scale graded from 0–100%

Full article at:   http://goo.gl/3UJ5wA

By:  Christine M. Wilder, M.D.,1,2,* Shannon C. Miller, M.D.,1,2 Elizabeth Tiffany, M.D.,2 Theresa Winhusen, Ph.D.,2 Erin L. Winstanley, Ph.D.,3 and Michael D. Stein, M.D.4

¹Department of Veterans Affairs Medical Center, 3200 Vine Street, Cincinnati, OH 45220

²Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229

³James L. Winkle College of Pharmacy, University of Cincinnati, PO Box 670004, Cincinnati, OH 45267-0004

⁴Department of Medicine, Alpert School of Medicine of Brown University, Butler Hospital, 345 Blackstone Blvd, Providence, RI 09206

^*Corresponding Author: Christine M. Wilder, MD; Email: ude.cu@redliw.enitsirhC

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Drug Overdoses in the US

Below:  https://atlas.qz.com/charts/EJHSfd6rl

Correlates of Overdose Risk Perception among Illicit Opioid Users

BACKGROUND:

Opioid-related mortality continues to increase in the United States. The current study assesses demographic and behavioral predictors of perceived overdose risk among individuals who use opioids illicitly. By examining these correlates in the context of established overdose risk factors, we aim to assess whether characteristics and behaviors that have been associated with actual overdose risk translate to higher perception of risk.

METHODS:

We conducted a cross-sectional survey of 172 adult illicit opioid users in San Francisco, CA and used multivariable logistic regression to identify predictors of perception of high risk for opioid overdose.

RESULTS:

Age (aOR=0.96, 95%CI=0.93-1.00) and number of injection days per month (0.91, 0.86-0.97) were associated with a lower odds of perceived high overdose risk. There was no independent association between use of opioid analgesics, concurrent use of opioids and benzodiazepines or cocaine, or HIV status and overdose risk perception.

CONCLUSIONS:

Opioid users who injected more frequently and those who were older were less likely to perceive themselves as being at risk of overdose, notwithstanding that those who inject more are at higher risk of overdose and those who are older are at higher risk overdose mortality. In addition, despite being established overdose risk factors, there was no relationship between use of opioid analgesics, concurrent use of opioids and cocaine or benzodiazepines, or self-reported HIV status and overdose risk perception. These findings highlight key populations of opioid users and established risk factors that may merit focused attention as part of education-based overdose prevention and opioid management strategies.

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By:  Rowe C1, Santos GM2, Behar E3, Coffin PO2.

• 1San Francisco Department of Public Health, 25 Van Ness Avenue, Suite 500, San Francisco, CA 94102, USA. Electronic address: chris.rowe@sfdph.org.
• 2San Francisco Department of Public Health, 25 Van Ness Avenue, Suite 500, San Francisco, CA 94102, USA; University of California, San Francisco, 500 Parnassus Avenue, San Francisco, CA 94143, USA.
• 3San Francisco Department of Public Health, 25 Van Ness Avenue, Suite 500, San Francisco, CA 94102, USA. 
• Drug Alcohol Depend. 2015 Dec 30. pii: S0376-8716(15)01833-5. doi: 10.1016/j.drugalcdep.2015.12.018. 

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What are opioids:  http://goo.gl/ncoQ9R 

Prevention of Injury and Violence in the USA

In the first three decades of life, more individuals in the USA die from injuries and violence than from any other cause. Millions more people survive and are left with physical, emotional, and financial problems. Injuries and violence are not accidents; they are preventable. Prevention has a strong scientific foundation, yet efforts are not fully implemented or integrated into clinical and community settings. In this Series paper, we review the burden of injuries and violence in the USA, note effective interventions, and discuss methods to bring interventions into practice. Alliances between the public health community and medical care organisations, health-care providers, states, and communities can reduce injuries and violence. We encourage partnerships between medical and public health communities to consistently frame injuries and violence as preventable, identify evidence-based interventions, provide scientific information to decision makers, and strengthen the capacity of an integrated health system to prevent injuries and violence.

Below:  Top 10 leading causes of death for ages 1 to 30 years – United States, 2010

Below:  Age-adjusted suicide and homicide rates by race/ethnicity – United States, 2010

Below:  Rates of opioid overdose deaths, sales and treatment admissions – United States, 1999–2010

Full article at:   http://goo.gl/xH8Uiq

By:  Tamara M Haegerich, Linda L Dahlberg, Thomas R Simon, Grant T Baldwin, David A Sleet, and Arlene I Greenspan

National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, US Department of Health and Human Services, Atlanta, GALinda C Degutis, Independent Consultant, Atlanta, GA

Correspondence to: Dr. Tamara M Haegerich, Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA 30341, USA, Email: vog.cdc@hciregeaht

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Patient Perspectives on an Opioid Overdose Education and Naloxone Distribution Program in the US Department of Veterans Affairs

BACKGROUND:

In an effort to prevent opioid overdose mortality among Veterans, Department of Veterans Affairs (VA) facilities began implementing Opioid Overdose Education and Naloxone Distribution (OEND) in 2013 and a national program began in 2014. VA is the first national health care system to implement OEND. The goal of this study is to examine patient perceptions of OEND training and naloxone kits.

METHODS:

Four focus groups were conducted between December 2014 and February 2015 with 21 patients trained in OEND. Participants were recruited from a VA residential facility in California with a substance use disorder treatment program (mandatory OEND training) and a homeless program (optional OEND training). Data were analyzed using matrices and open and closed coding approaches to identify what participants liked and did not like, group discussion disagreements, and suggestions for improvement.

RESULTS:

Veterans thought OEND training was interesting, novel, and empowering, and that naloxone kits will save lives. Some veterans expressed concern about using syringes in the kits. A few patients who never used opioids were not interested in receiving kits. Veterans had differing opinions about legal and liability issues, whether naloxone kits might contribute to relapse, and whether and how to involve family in training. Some veterans expressed uncertainty about the effects of naloxone. Suggested improvements included active learning approaches, enhanced training materials, and increased advertisement.

CONCLUSIONS:

OEND training was generally well-received among study participants, including those with no indication for a naloxone kit. Patients described a need for OEND and believed it could save lives. Patient feedback on OEND training benefits, concerns, opinions, and suggestions provides important insights to inform future OEND training programs both within VA and in other health care settings. Training is critical to maximizing the potential for OEND to save lives and this study includes specific suggestions for improving the effectiveness and acceptability of training.

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By:  Oliva EM1, Nevedal A1, Lewis ET1,2, McCaa MD1, Cochran MF1,3, Konicki PE4,5, Davis CS6, Wilder C7,8.

• 1 VA Palo Alto Health Care System - Center for Innovation to Implementation , Menlo Park , CA , USA.
• 2 VA Office of Mental Health Operations - Program Evaluation and Resource Center , Menlo Park , CA , USA.
• 3 Stanford University School of Medicine - Department of Psychiatry and Behavioral Sciences , Stanford , CA , USA.
• 4 Louis Stokes Cleveland VA Medical Center , Cleveland , OH , USA.
• 5 Case Western Reserve University School of Medicine - Department of Psychiatry , Cleveland , OH , USA.
• 6National Health Law Program , Los Angeles , CA , USA.
• 7 Cincinnati VA Medical Center , Cincinnati , OH , USA.
• 8 University of Cincinnati College of Medicine - Department of Psychiatry and Behavioral Neuroscience , Cincinnati , OH , USA.
• Subst Abus. 2015 Dec 16:0. 

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Risk Factors of Prescription Opioid Overdose among Colorado Medicaid Beneficiaries

Highlights

• This article presents the risk factors of opioid overdose among the Colorado Medicaid population.
• Six factors were associated with opioid overdose including mean morphine dose equivalent (>50 mg/day), methadone use, drug/alcohol abuse, psychiatric illness, benzodiazepine use, and the number of different pharmacies used by the beneficiary.
• States and communities should ensure the availability of at-home intra-nasal naloxone for overdose rescue based on the presence of risk factors.

This study aims to determine risk factors of opioid overdose among the Colorado Medicaid population. A retrospective nested case-control study was undertaken. Medicaid beneficiaries who had a medical claim(s) for an emergency department visit or a hospitalization associated with an opioid overdose from July 2009 to June 2014 were defined as cases. Controls were selected using a nearest neighbor matching without replacement. The matched controls were selected based on age, gender, and opioid prescription. One case was matched with three controls. Multivariate conditional logistic regression was used to compare risk factors. 

A total of 816 cases with 2,448 controls were included. Six factors were associated with opioid overdose: mean morphine dose equivalent (>50 mg/day), methadone use (switching opioid to methadone vs. no methadone use), drug/alcohol abuse, other psychiatric illness, benzodiazepine use, and the number of pharmacies utilized by the beneficiary (≥4 pharmacies vs. 1 pharmacy). 

In conclusion, several factors are associated with opioid overdose. States and communities should ensure the availability of at-home intra-nasal naloxone for overdose rescue based on the presence of risk factors.

PERSPECTIVES:

This article presents the risk factors of opioid overdose among Colorado Medicaid population. Based on study findings, Colorado Medicaid is currently working with physicians, hospitals, and other health-system stakeholders to continue develop policies to identify and assist this subset of our population. One such policy will be to provide intranasal naloxone for overdose rescue.

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By:   Dilokthornsakul P1, Moore G2, Campbell JD2, Lodge R3, Traugott C3, Zerzan J3, Allen R4, Page RL 2nd2.

• 1Center for Pharmaceutical Outcomes Research, Skaggs School of Pharmacy and Pharmaceutical Sciences (http://www.ucdenver.edu/academics/colleges/pharmacy/Pages/SchoolofPharmacy.aspx), University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Center of Pharmaceutical Outcomes Research, Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand. Electronic address: piyamethd@gmail.com.
• 2Center for Pharmaceutical Outcomes Research, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
• 3Department of Health Care Policy and Financing, State of Colorado.
• 4Peak Statistical Services, Evergreen, CO, USA.
• J Pain. 2015 Dec 22. pii: S1526-5900(15)00985-2. doi: 10.1016/j.jpain.2015.12.006.
• 
  
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Opioid Prescribing After Nonfatal Overdose and Association with Repeated Overdose

BACKGROUND:

Nonfatal opioid overdose is an opportunity to identify and treat substance use disorders, but treatment patterns after the overdose are unknown.

OBJECTIVE:

To determine prescribed opioid dosage after an opioid overdose and its association with repeated overdose.

SETTING:

A large U.S. health insurer.

PARTICIPANTS:

2848 commercially insured patients aged 18 to 64 years who had a nonfatal opioid overdose during long-term opioid therapy for noncancer pain between May 2000 and December 2012.

MEASUREMENTS:

Nonfatal opioid overdose was identified using International Classification of Diseases, Ninth Revision, Clinical Modification, codes from emergency department or inpatient claims. The primary outcome was daily morphine-equivalent dosage (MED) of opioids dispensed from 60 days before to up to 730 days after the index overdose. We categorized dosages as large (≥100 mg MED), moderate (50 to <100 mg MED), low (<50 mg MED), or none (0 mg MED). Secondary outcomes included time to repeated overdose stratified by daily dosage as a time-varying covariate.

RESULTS:

Over a median follow-up of 299 days, opioids were dispensed to 91% of patients after an overdose. Seven percent of patients (n = 212) had a repeated opioid overdose. At 2 years, the cumulative incidence of repeated overdose was 17% (95% CI, 14% to 20%) for patients receiving high dosages of opioids after the index overdose, 15% (CI, 10% to 21%) for those receiving moderate dosages, 9% (CI, 6% to 14%) for those receiving low dosages, and 8% (CI, 6% to 11%) for those receiving no opioids.

LIMITATION:

The cohort was limited to commercially insured adults.

CONCLUSION:

Almost all patients continue to receive prescription opioids after an overdose. Opioid discontinuation after overdose is associated with lower risk for repeated overdose.

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By:   Larochelle MR, Liebschutz JM, Zhang F, Ross-Degnan D, Wharam JF.

From Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston University School of Medicine, and Boston Medical Center, Boston, Massachusetts.

Ann Intern Med. 2015 Dec 29. doi: 10.7326/M15-0038. [Epub ahead of print]

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An Initial Evaluation of Web-Based Opioid Overdose Education

BACKGROUND:

Fatal opioid overdose is a significant public health concern in the United States. One approach to reducing fatalities is expanding overdose response education to broader audiences. This study examined responses to a web-based overdose education tool.

METHODS:

The results of 422 anonymous surveys submitted on www.stopoverdose.org were analyzed for participant demographics, knowledge of opioid overdose recognition and response, and knowledge of Washington's Good Samaritan overdose law. Characteristics, knowledge, and planned behavior of respondents with professional versus personal interest in overdose education were compared.

RESULTS:

Most respondents were age 35 or older (57%) and female (65%). The mean score on the knowledge quiz for overdose recognition and response items was 16.2 out of 18, and 1.5 out of 2 possible points for items concerning the law. Respondents indicating professional interest were significantly more likely to be 35 or older (p = .001) and to have received prior overdose education (p < .001), but less likely to know someone at risk for opioid overdose (p < .001) or report planning to obtain take-home naloxone (p < .001). No significant differences were found in overdose knowledge scores between groups.

CONCLUSIONS:

Online training may be effective among individuals with professional and personal interest in overdose, as general knowledge scores of overdose response were high among both groups. Lower scores reflecting knowledge of the law suggest that the web-based training may not have adequately presented this information. Overall, results suggest that a web-based platform may be a promising approach to basic overdose education.

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By:   Roe SS¹, Banta-Green CJ².

¹ Social Development Research Group , University of Washington , Seattle , Washington , USA.

² Alcohol and Drug Abuse Institute , University of Washington , Seattle , Washington , USA.

DOI:

10.3109/10826084.2015.1092986

 

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Prevalence & Experience of Chronic Pain in Suburban Drug Injectors

AIMS:

To explore the relationship between chronic pain and characteristics, behaviors, and psychological status of suburban Connecticut injection drug users.

METHODS:

Cross-sectional study with quantitative interview and serological testing for HIV and hepatitis B and C in 456 individuals who injected drugs in the past month. Participants were dichotomized into those reporting current chronic pain of at least six months duration and all others. The interview covered 

1. sociodemographics, 
2. injection drug use, 
3. interactions with drug treatment, criminal justice, and harm reduction, 
4. screening for alcohol use, chronic pain, anxiety, and depression, and 
5. knowledge regarding HIV, hepatitis B (HBV) and C (HCV), and opioid overdose. 

Serological testing for HIV, HBV, and HCV was conducted.

RESULTS:

One-third (n = 143) reported chronic pain. These individuals differed significantly from those not reporting chronic pain on characteristics that included older age, lower educational achievement, and injection of pharmaceutical opioids. They also reported experiencing more psychological and family problems on the ASI and higher levels of depression and anxiety. Four of five individuals with chronic pain (n = 117) reported non-medical opioid use prior to the onset of chronic pain.

CONCLUSIONS:

Chronic pain is common among drug injectors in our study population although it was unusual for chronic pain to have preceded non-medical opioid use. Psychological problems in injectors with co-occurring chronic pain are likely pose significant complications to successful treatment for substance abuse, pain, or infectious disease treatment.

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By:   Heimer R¹, Zhan W², Grau LE².

¹Center for Interdisciplinary Research on AIDS and the Department of Epidemiology of Microbial Disease, Yale University School of Public Health, 60 College Street, New Haven, CT 06520, United States. Electronic address: robert.heimer@yale.edu.

²Center for Interdisciplinary Research on AIDS and the Department of Epidemiology of Microbial Disease, Yale University School of Public Health, 60 College Street, New Haven, CT 06520, United States.

  

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Revisiting the Role of the Urban Environment in Substance Use: The Case of Analgesic Overdose Fatalities

Objectives. We examined whether neighborhood social characteristics (income distribution and family fragmentation) and physical characteristics (clean sidewalks and dilapidated housing) were associated with the risk of fatalities caused by analgesic overdose.

Methods. In a case-control study, we compared 447 unintentional analgesic opioid overdose fatalities (cases) with 3436 unintentional nonoverdose fatalities and 2530 heroin overdose fatalities (controls) occurring in 59 New York City neighborhoods between 2000 and 2006.

Results. Analgesic overdose fatalities were less likely than nonoverdose unintentional fatalities to have occurred in higher-income neighborhoods (odds ratio [OR] = 0.82; 95% confidence interval [CI] = 0.70, 0.96) and more likely to have occurred in fragmented neighborhoods (OR = 1.35; 95% CI = 1.05, 1.72). They were more likely than heroin overdose fatalities to have occurred in higher-income (OR = 1.31; 95% CI = 1.12, 1.54) and less fragmented (OR = 0.71; 95% CI = 0.55, 0.92) neighborhoods.

Conclusions. Analgesic overdose fatalities exhibit spatial patterns that are distinct from those of heroin and nonoverdose unintentional fatalities. Whereas analgesic fatalities typically occur in lower-income, more fragmented neighborhoods than nonoverdose fatalities, they tend to occur in higher-income, less unequal, and less fragmented neighborhoods than heroin fatalities.

Full article at:  http://goo.gl/EZ0lEW

By:  Magdalena Cerdá, DrPH, Yusuf Ransome, MS, Katherine M. Keyes, PhD, Karestan C. Koenen, PhD, Kenneth Tardiff, MD, David Vlahov, RN, PhD, and Sandro Galea, MD, DrPH

Magdalena Cerdá, Katherine M. Keyes, Karestan C. Koenen and Sandro Galea are with the Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY. Yusuf Ransome is with the Department of Sociomedical Sciences, Columbia University Mailman School of Public Health. Kenneth Tardiff is with the Department of Psychiatry, Weill Cornell Medical College, New York, NY. David Vlahov is with the School of Nursing, University of California, San Francisco.

Corresponding author.

Correspondence should be sent to Magdalena Cerdá, DrPH, MPH, Department of Epidemiology, Columbia University Mailman School of Public Health, 722 W168th St, Room 527, New York, NY 10032 (e-mail: ude.aibmuloc@6223cm). Reprints can be ordered at http://www.ajph.org by clicking on the “Reprints” link.

Peer Reviewed

Contributors

M. Cerdá designed the analysis, conducted the literature review, and wrote the article. Y. Ransome collaborated on the design of the analysis, implemented the analysis, and provided input on the article. K. M. Keyes and K. C. Koenen collaborated on the analysis plan and literature review and substantially edited all sections of the article. K. Tardiff and D. Vlahov collaborated on the design and implementation of the study and edited all sections of the article. S. Galea collaborated on the design and implementation of the study, as well as on the design of the analysis, and substantially edited all sections of the article.

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