Presentation delivered at the University of Michigan Injury Center Opioid Overdose Summit, Ann Arbor, MI, December 1, 2015

1. Prescription Drug Poisoning: No
Longer A Silent Epidemic
Christy Porucznik, PhD MSPH

2. 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

3. National Status, 2014
41,340 deaths
16,917 deaths
Nearly 4x increase
since 1999

4. Death Certificates
as a Data Source
• Underlying causes of death classified using ICD-
10 and selected by the drug poisoning codes

5. • 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

6. US Death Certificates:
Consider Age

7. • 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

8. US Death Certificates:
Categories of Analgesics

9. Utah Medical Examiner
Database

10. US Death Certificates:
Benzodiazepines and Opioids

11. 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

12. 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 2003
Year
NumberofDrugOverdoseDeaths
Illicit Drugs Only
Non-Illicit Drugs
Only
Both Illicit and Non-
Illicit Drugs

13. 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

14. Questions
• Was this a patient
safety problem?
• Was this a law
enforcement
problem?
• Was it both?

15. 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

16. 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

17. 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

18. Prescription Pain
Medication:
What you need to know
Credit for these
slides to
Erin Johnson, MPH
www.useonlyasdirected.org www.health.utah.gov/prescription

19. HB 137: Legislative Charge
July 2007-2009
• Research
– Causes, risk factors, solutions
• Create Guidelines
• Educate
– Health Care Providers
– Patients
– Insurers
– General Public

20. Mean Annual ED Visits Per Patient by
Year and Patient Type
0
1
2
3
4
51998
1999
2000
2001
2002
2003
2004
2005
2006
MeanAnnualEDVisitsPerPatient
byYearandPatientType
Patients with any opioid-related visits
Patients with no opioid-related visits

21. 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

22. • 87.4% of decedents had taken prescription
pain medication within 1 year of death
Reporting 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

23. • 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%

24. 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

25. 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

26. 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

27. 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

28. 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

29. Television

30. Radio

31. Website

32. Collateral materials

33. Print advertisements

34. Community events and displays

35. Coverage in the news media

36. Tracking hits to the website

37. 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

38. Utah Clinical Guidelines on
Prescribing Opioids
• Based on 7 evidence-based guidelines
• Utah consensus product
• Mandated by legislature
• Accompanied by implementation tools

39. 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

40. 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

41. 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

42. 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

43. Annual Number of Unique
Opioid Patients in the CSD
580000
600000
620000
640000
660000
680000
700000
720000
740000
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

44. Annual Unique Methadone
Patients in the CSD
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

45. Rx Opioid-Related Deaths
Investigated by the Medical
Examiner, Utah 2000-2014
0
50
100
150
200
250
300
350
200020012002200320042005200620072008200920102011201220132014
UDOH received funding for
prescription pain medication
education and research
2014 data are preliminary
Funding
eliminated

46. • 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)

47. 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

48. System use has increased
H.B. 28 passed,
March 2010
H.B. 28 takes effect,
September 2010

49. 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

50. 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

52. 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

53. Utah CSD: Methadone Initiation
ACUTE CHRONIC INTERMITTENT PALLIATIVE ALL USERS
PRE 9.08% 18.41% 24.28% 46.04% 21.24%
INTERMEDIATE 6.96% 16.44% 23.56% 48.96% 19.68%
POST 5.12% 11.67% 17.04% 41.90% 13.89%
0%
10%
20%
30%
40%
50%
60%
Proportion
Proportion of Any Methadone Flags
by User Type and Time Period

54. Utah CSD: Dual Use
of Long Acting Opioids
ACUTE CHRONIC INTERMITTENT PALLIATIVE ALL USERS
PRE 0.00% 7.99% 1.17% 4.36% 4.17%
INTERMEDIATE 0.04% 6.04% 0.88% 4.60% 3.40%
POST 0.00% 3.20% 0.65% 2.14% 2.12%
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
Proportion
Proportion of Dual Use of Long-acting Opioids
by User Type and Time Period

55. Linked Utah CSD and ED: Opioid-
Related ED Visits Among Patients
ACUTE CHRONIC INTERMITTENT PALLIATIVE ALL USERS
PRE 0.06% 1.06% 0.27% 0.27% 0.19%
INTERMEDIATE 0.06% 0.91% 0.27% 0.31% 0.18%
POST 0.05% 0.55% 0.21% 0.26% 0.14%
0.0%
0.2%
0.4%
0.6%
0.8%
1.0%
1.2%
Proportion
Proportion of Opioid Related ED Visits
by User Type and Time Period

56. 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

57. 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

58. 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

59. Questions?
Christy Porucznik, PhD MSPH
christy.porucznik@utah.edu