Joseph E. Logan

Patterns of Abuse Among Unintentional Pharmaceutical Overdose Fatalities

CONTEXT Use and abuse of prescription narcotic analgesics have increased dramatically in the United States since 1990. The effect of this pharmacoepidemic has been most pronounced in rural states, including West Virginia, which experienced the nations largest increase in drug overdose mortality rates during 1999-2004. OBJECTIVE To evaluate the risk characteristics of persons dying of unintentional pharmaceutical overdose in West Virginia, the types of drugs involved, and the role of drug abuse in the deaths. DESIGN, SETTING, AND PARTICIPANTS Population-based, observational study using data from medical examiner, prescription drug monitoring program, and opiate treatment program records. The study population was all state residents who died of unintentional pharmaceutical overdoses in West Virginia in 2006. MAIN OUTCOME MEASURES Rates and rate ratios for selected demographic variables. Prevalence of specific drugs among decedents and proportion that had been prescribed to decedents. Associations between demographics and substance abuse indicators and evidence of pharmaceutical diversion, defined as a death involving a prescription drug without a documented prescription and having received prescriptions for controlled substances from 5 or more clinicians during the year prior to death (ie, doctor shopping). RESULTS Of 295 decedents, 198 (67.1%) were men and 271 (91.9%) were aged 18 through 54 years. Pharmaceutical diversion was associated with 186 (63.1%) deaths, while 63 (21.4%) were accompanied by evidence of doctor shopping. Prevalence of diversion was greatest among decedents aged 18 through 24 years and decreased across each successive age group. Having prescriptions for a controlled substance from 5 or more clinicians in the year prior to death was more common among women (30 [30.9%]) and decedents aged 35 through 44 years (23 [30.7%]) compared with men (33 [16.7%]) and other age groups (40 [18.2%]). Substance abuse indicators were identified in 279 decedents (94.6%), with nonmedical routes of exposure and illicit contributory drugs particularly prevalent among drug diverters. Multiple contributory substances were implicated in 234 deaths (79.3%). Opioid analgesics were taken by 275 decedents (93.2%), of whom only 122 (44.4%) had ever been prescribed these drugs. CONCLUSION The majority of overdose deaths in West Virginia in 2006 were associated with nonmedical use and diversion of pharmaceuticals, primarily opioid analgesics.

A comparison of drug overdose deaths involving methadone and other opioid analgesics in West Virginia

AIMS To describe all people dying from unintentional overdoses of methadone or other opioid analgesics (OOA) in West Virginia in 2006. DESIGN We analyzed medical examiner data supplemented by data from the state prescription drug monitoring program. We compared people whose deaths involved methadone with those whose deaths involved OOA. FINDINGS The methadone group included 87 decedents, and the OOA group included 163 decedents. Most were male. Decedents in the methadone group were significantly younger than those in the OOA group: more than a quarter were 18-24 years of age. For both groups, approximately 50% had a history of pain, and 80% had a history of substance abuse. There was no intergroup difference in the prevalence of benzodiazepines at post-mortem. Methadone was significantly less likely to have ever been prescribed than OOA. Among those with prescriptions, the proportion prescribed within 30 days of death was significantly greater for methadone than for hydrocodone, but not for oxycodone. Ten (11.5%) of the methadone decedents were enrolled in an opiate treatment program (OTP) at the time of death. CONCLUSIONS The high prevalence of a substance abuse history and lack of prescriptions suggest that most of the deaths in both groups are related to substance abuse. There was no indication of a harmful effect from methadones metabolic interaction with benzodiazepines, but provider or patient unfamiliarity with methadone may have been a risk factor. Prescribing methadone, especially to young males, requires extra care. Providers, OTPs and coroners/medical examiners should use state prescription drug monitoring programs to monitor the use of controlled substances by their patients.

Mental Illness and Psychotropic Drug Use Among Prescription Drug Overdose Deaths: A Medical Examiner Chart Review

OBJECTIVE Between 1999 and 2006, there was a 120% increase in the rate of unintentional drug overdose deaths in the United States. This study identifies the prevalence of mental illness, a risk factor for substance abuse, and chronic pain among prescription drug overdose deaths in West Virginia and ascertains whether psychotropic drugs contributing to the deaths were used to treat mental illness or for nonmedical purposes. METHOD In 2007, we abstracted data on mental illness, pain, and drugs contributing to death from all unintentional prescription drug overdose deaths in 2006 recorded by the West Virginia Office of the Chief Medical Examiner. Decedent prescription records were obtained from the state prescription drug monitoring program. RESULTS Histories of mental illness and pain were documented in 42.7% and 56.6% of 295 decedents, respectively. Psychotropic drugs contributed to 48.8% of the deaths, with benzodiazepines involved in 36.6%. Benzodiazepines contributing to death were not associated with mental illness (adjusted odds ratio [AOR] = 1.1; 95% CI, 0.6-1.8), while all other psychotropic drugs were (AOR = 3.9; 95% CI, 2.0-7.6). Of decedents with contributory benzodiazepines, 46.3% had no prescription for the drug. CONCLUSIONS Mental illness may have contributed to substance abuse associated with deaths. Clinicians should screen for mental illness when prescribing opioids and recommend psychotherapy as an adjunct or an alternate to pharmacotherapy. Benzodiazepines may have been used nonmedically rather than as a psychotropic drug, reflecting drug diversion. Restricting benzodiazepine prescriptions to a 30-day supply with no refills might be considered.

Opioid prescribing in emergency departments: the prevalence of potentially inappropriate prescribing and misuse.

Objective:Emergency departments (EDs) routinely provide care for patients seeking treatment for painful conditions; however, they are also targeted by people seeking opioid analgesics for nonmedical use. This study determined the prevalence of indicators of potential ED opioid misuse and inappropriate prescription practices by ED providers in a large, commercially insured, adult population. Research Design and Indicators:We analyzed the 2009 Truven Health MarketScan® Research Databases to examine the ED visits of enrollees aged 18–64 years. Indicators used to mark potential inappropriate use included opioid prescriptions overlapping by one week or more; overlapping opioid and benzodiazepine prescriptions; high daily doses (≥100 morphine milligram equivalents); long-acting/extended-release (LA/ER) opioids for acute pain, and overlapping LA/ER opioids. Analyses were stratified by sex. Results:We identified 400,288 enrollees who received at least one ED opioid prescription. At least one indicator applied to 10.3% of enrollees: 7.7% had high daily doses; 2.0% had opioid overlap; 1.0% had opioid-benzodiazepine overlap. Among LA/ER opioid prescriptions, 21.7% were for acute pain, and 14.6% were overlapping. Females were more likely to have at least one indicator. Conclusions:In some instances, the prescribing of opioid analgesics in EDs might not be optimal in terms of minimizing the risk of their misuse. Guidelines for the cautious use of opioid analgesics in EDs and timely data from prescription drug monitoring programs could help EDs treat patients with pain while reducing the risk of nonmedical use.

Precipitating Circumstances of Suicide Among Youth Aged 10–17 Years by Sex: Data From the National Violent Death Reporting System, 16 States, 2005–2008

We examined the circumstances that precipitated suicide among 1,046 youth aged 10-17 years in 16 U.S. states from 2005 to 2008. The majority of deaths were among male subjects (75.2%), non-Hispanic whites (69.3%), those aged 16-17 years (58.1%), those who died by hanging/strangulation/suffocation (50.2%) and those who died in a house or an apartment (82.5%). Relationship problems, recent crises, mental health problems, and intimate partner and school problems were the most common precipitating factors and many differed by sex. School problems were reported for 25% of decedents, of which 30.3% were a drop in grades and 12.4% were bullying related. Prevention strategies directed toward relationship-building, problem-solving, and increasing access to treatment may be beneficial for this population.

Characteristics of Suicides Among US Army Active Duty Personnel in 17 US States From 2005 to 2007

Suicides are increasing among active duty US Army soldiers. To help focus prevention strategies, we characterized 56 US Army suicides that occurred from 2005 to 2007 in 17 US states using 2 large-scale surveillance systems. We found that intimate partner problems and military-related stress, particularly job stress, were common among decedents. Many decedents were also identified as having suicidal ideation, a sad or depressed mood, or a recent crisis before death. Focusing efforts to prevent these forms of stress might reduce suicides among soldiers.

A detailed exploration into the association of prescribed opioid dosage and overdose deaths among patients with chronic pain

Background:High opioid dosage has been associated with overdose, and clinical guidelines have cautioned against escalating dosages above 100 morphine-equivalent mg (MEM) based on the potential harm and the absence of evidence of benefit from high dosages. However, this 100 MEM threshold was chosen somewhat arbitrarily. Objective:To examine the association of prescribed opioid dosage as a continuous measure in relation to risk of unintentional opioid overdose to identify the range of dosages associated with risk of overdose at a detailed level. Methods:In this nested case-control study with risk-set sampling of controls, cases (opioid overdose decedents) and controls were identified from a population of patients of the Veterans Health Administration who were prescribed opioids and who have a chronic pain diagnosis. Unintentional fatal opioid analgesic overdose was measured from National Death Index records and prescribed opioid dosage from pharmacy records. Results:The average prescribed opioid dosage was higher (P<0.001) for cases (mean=98.1 MEM, SD=112.7; median=60, interquartile range, 30–120), than controls (mean=47.7 MEM, SD=65.2; median=25, interquartile range, 15–45). In a ROC analysis, dosage was a moderately good “predictor” of opioid overdose death, indicating that, on average, overdose cases had a prescribed opioid dosage higher than 71% of controls. Conclusions:A clear cut-point in opioid dosage to distinguish between overdose cases and controls was not found. However, lowering the recommended dosage threshold below the 100 MEM used in many recent guidelines would affect proportionately few patients not at risk for overdose while potentially benefitting many of those at risk for overdose.

Gender-Specific Mental and Behavioral Outcomes Among Physically Abused High-Risk Seventh-Grade Youths

Objective. Research has shown that physical abuse during childhood (early PA) is associated with various mental and behavioral problems in adolescence. However, there is little research on the differences in these associations by gender among youths residing in high-risk communities. This study investigated gender differences in the relationship between early PA and various internalizing (e.g., thoughts of suicide or victimization) and externalizing (e.g., perpetration of violence) behaviors. Methods. A cross-sectional study was conducted using survey data (collected in 2004) provided by 1,484 seventh-grade youths residing in a high-risk community (83% participated). Students were considered victims of early PA if they reported experiencing abuse prior to age 10 years. Prevalence ratios (PRs) were calculated to estimate the association between early PA and various outcomes (e.g., suicidality, victimization, violence, and illegal drug use), adjusting for race/ethnicity and other forms of abuse. Poisson regression with robust variance estimates was used to estimate the PRs and test for early PA-gender interaction. Results. Early PA was positively associated with suicidality, illegal drug use, and victimization with no significant differences by gender. The association between early PA and criminal behavior was significantly higher for females; the association between early PA and peer violence perpetration was significantly higher for males (interaction term PA*gender was significant at the p≤0.005 level). Conclusions. Young high-risk adolescents who experienced early PA may need counseling or other services (e.g., home visitation) to help prevent suicidality, victimization, violence perpetration, criminal behavior, and illegal drug use. Furthermore, male victims may need more attention in the area of violence prevention; female victims may need particular attention with regard to preventing criminal behavior.

Precipitating Circumstances of Suicide among Active Duty U.S. Army Personnel Versus U.S. Civilians, 2005–2010

To help understand suicide among soldiers, we compared suicide events between active duty U.S. Army versus civilian decedents to identify differences and inform military prevention efforts. We linked 141 Army suicide records from 2005 to 2010 to National Violent Death Reporting System (NVDRS) data. We described the decedents’ military background and compared their precipitators of death captured in NVDRS to those of demographically matched civilian suicide decedents. Both groups commonly had mental health and intimate partner precipitating circumstances, but soldier decedents less commonly disclosed suicide intent.

Deciphering Suicide and Other Manners of Death Associated with Drug Intoxication: A Centers for Disease Control and Prevention Consultation Meeting Summary.

Manner of death (MOD) classification (i.e., natural, accident, suicide, homicide, or undetermined cause) affects mortality surveillance and public health research, policy, and practice. Determination of MOD in deaths caused by drug intoxication is challenging, with marked variability across states. The Centers for Disease Control and Prevention hosted a multidisciplinary meeting to discuss drug intoxication deaths as they relate to suicide and other MOD. The meeting objectives were to identify individual-level, system-level, and place-based factors affecting MOD classification and identify potential solutions to classification barriers. Suggested strategies included improved standardization in death scene investigation, toxicology, and autopsy practice; greater accountability; and creation of job aids for investigators. Continued collaboration and coordination of activities are needed among stakeholders to affect prevention efforts.