Prescription Opioids: Extramedical Use and Overdose Amy S.B. Bohnert, Ph.D. VA National Serious...
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Prescription Opioids: Extramedical Use and Overdose
Amy S.B. Bohnert, Ph.D.
VA National Serious Mental Illness Treatment Resource & Evaluation CenterVA Ann Arbor HSR&D Center of Excellence, Center for Clinical Management Research
University of Michigan Medical School, Department of Psychiatry
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AcknowledgementsSupported by funding from Veteran Health Administration, Office of Mental
Health Services and VA HSR&D grant CDA-09-204, and the University of Michigan Department of Psychiatry and Injury Center.
No conflicts of interest to report.
Collaborators:Matt Bair
Frederic BlowAnna Eisenberg
Dara GanoczyRose IgnacioMark Ilgen
John McCarthyAmanda Price
Marcia Valenstein
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Prescription Opioids: Research Goals
• What are groups that have a high prevalence of use? Where can they be found?
• How can we better measure prescription opioid use that is not part of medical care?
• How can we reduce the harms associated with prescription opioids (OVERDOSE)?
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Use of Prescription Opioids in the U.S.
Pain Treatment Extramedical Use
Prescription Opioids: pain medications that contain opioids (naturally occurring or synthetic) and require a prescription in the U.S., including codeine, percocet, fentanyl etc.
Non-Medical Use
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Non-Medical Prescription Opioid Use in the U.S.
Source: SAMSHA
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Research Goals 1 + 2
• What are groups that have a high prevalence of use? Where can they be found?
• How can we better measure prescription opioid use that is not part of medical care?
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Study 1: Extramedical use among patients at a residential addictions treatment program
• Residential Treatment Unit- addictions treatment in which patients live together at the treatment center – Use is likely to be common- allows us to consider measurement issues
• Cross-sectional survey, n = 351
• Participants largely in treatment for alcohol or cocaine use-related problems
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Opioid Use Measurement (past 30 days)
1 item from the Addiction Severity Index (ASI)• Days used non-prescribed opiates/analgesics
6 items from the Current Opiate Misuse Measure (COMM) • Scale: Never – Rarely – Sometimes – Often – Very Often
– Taking medication belonging to someone else– Going to someone other than the prescribing physician– Taking more than prescribed– Taking differently than prescribed– Using for symptoms other than pain (e.g., improve mood, help sleep, relieve
stress)– Borrowed pain medications
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Study 1 Results: Past 30 Day Extramedical Use
COMM: 68% (n = 238) endorsed at least one of six items
ASI: 25% (n = 89) reported at least one day of use
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Price, Ilgen, & Bohnert, 2011 JSAT
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Motives for Opioid Pain Medication Use
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Study 2: Extramedical use among emergency department (ED) patients
• EDs have an elevated prevalence of drug use, are a location of brief intervention trials
• ED-based study of prescription opioid use– Survey of 1,027 patients age 18-60 presenting at
an urban ED• 33% in ED for an injury
– 4 modified COMM items to assess use
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Study 2: Results• Past 3 month opioid pain medication use
(including medical use): 49.5% (n = 508)– Among those with any use, 50.6% (n = 257)
reported extra-medical use (~25% sample)• Source non-medical: 47.1%• More than prescribed: 61.1%• For reasons other than pain relief: 35.0%• Some else’s Rx: 40.9%
– Of those with extramedical use, 20.2% had a prior non-fatal overdose
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Research Goal 3
• How can we reduce the harms associated with prescription opioids?– Dramatic increase in unintentional opioid
overdoses
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Fatal Accidental Overdoses are Increasing in the US
Bohnert, Fudalej, & Ilgen, 2010, Pub Health Rep
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Opioid Analgesics: Sales and Overdoses
Source: Medscape/CDC
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Causes of Prescription Opioid Overdose in the U.S.
Extra-Medical UsePain Treatment
Strategies:-Prescription monitoring systems-Prescribing practices-Patient and caregiver education
Strategies:-Diversion reduction
-Universal prevention to reduce initiation-Harm and use reduction
-Naloxone?
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Study 3: Prescription opioid overdoses among VHA patients
• Case-cohort study, 2004-2008• 1,136 prescription opioid overdose decedents (of
5,719,542 patients)• 750 (66%) had been prescribed opioids• Random Sample = 154,684• Data Sources: National Death Index, VHA Patient
Records• Focus on prescribing regimen (dose + schedule)
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From Bohnert, Bair, Valenstein et al., 2011 JAMA
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From Bohnert, Bair, Valenstein et al., 2011 JAMA
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Conclusions
• Non-medical/Extra-medical prescription opioid use is common among some specific sub-populations of adults
• Prescription opioid overdose is a pressing public health concern– A number of different types of interventions that
target medical use and non-medical use of prescription opioids are needed
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Future Directions
• What about other high-risk sub-groups?– Psychiatric patients
• Developing prescription opioid overdose prevention strategies– Extramedical Use
• Injury Center Pilot
– Medical Use• project on VA opioid prescribing