Leonard J. Paulozzi

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.

Pharmaceutical overdose deaths, United States, 2010.

risk reduction, be it cancer risk, cardiovascular risk, or progression of COPD. This potentially makes a negative outcome of screening counterproductive because it might be viewed as an incentive to continue smoking. However, smoking cessation remains difficult in any setting. Adherence is low and the outcome of screening has little longterm influence on smoking behavior. It recently has been shown that cardiovascular risk in smokers is increased, and this increase holds for any CAC score. Whereas the increased risk in smokers might suggest cardiovascular screening is not worthwhile in this population, the same study showed that mortality still increases substantially with higher CAC scores, even in smokers. These findings are corroborated by results from others, even in the setting of nongated chest CT scans used for cancer screening. Although the cardiovascular risk is increased on average, there is wide variation among smokers, which makes screening potentially useful to specifically detect those at high risk. Because smoking and CAC are independent risk factors, prediction will improve and not worsen when smoking and CAC and non-CAC are combined. Computed tomography technology currently used for lung cancer screening is limited by lack of electrocardiography gating. While this limitation reduces its value for excluding coronary calcium, the presence of larger amounts of calcium can be reliably detected, and the absolute risk of cardiovascular disease in individuals with high CAC scoring on screening scans is increased. Therefore, screening CT scans can readily establish increased risk. The real question is not whether to use the additional information provided by lung cancer screening but whether a highly positive result will be able to trigger treatment that can actually reduce this increased risk. For osteoporosis, quantitative CT of the lumbar spine had been superior to DEXA for measuring bone architecture and density. Technical and financial reasons have led to the widespread use of DEXA and to the decline of CT as an investigative tool. While osteoporosis assessment is generally performed on the lumbar spine, the thoracic spine is also affected and is readily assessable by chest CT. Direct implementation is hampered by the limited data available from most individuals, but it is not a reason why CT of the thoracic spine should not be able to detect osteopenia or osteoporosis. Although it is debated as to whether early diagnosis of COPD is useful, COPD and emphysema are independent predictors of lung cancer; therefore, detection may aid a more personalized and cost-effective lung cancer screening regimen. Independent of whether or not one supports CT-based lung cancer screening, extending this screening to other diseases that can be detected early by chest CT will provide valuable epidemiological data at least. At best, it may contribute to secondary prevention of some of the most debilitating diseases in the developed world.

Prescription Drug Monitoring Programs and Death Rates from Drug Overdose

OBJECTIVE Drug overdoses resulting from the abuse of prescription opioid analgesics and other controlled substances have increased in number as the volume of such drugs prescribed in the United States has grown. State prescription drug monitoring programs (PDMPs) are designed to prevent the abuse of such drugs. This study quantifies the relation of PDMPs to rates of death from drug overdose and quantities of opioid drugs distributed at the state level. DESIGN Observational study of the United States during 1999-2005. OUTCOME MEASURES Rates of drug overdose mortality, opioid overdose mortality, and opioid consumption by state. RESULTS PDMPs were not significantly associated with lower rates of drug overdose or opioid overdose mortality or lower rates of consumption of opioid drugs. PDMP states consumed significantly greater amounts of hydrocodone (Schedule III) and nonsignificantly lower amounts of Schedule II opioids. The increases in overdose mortality rates and use of prescription opioid drugs during 1999-2005 were significantly lower in three PDMP states (California, New York, and Texas) that required use of special prescription forms. CONCLUSIONS While PDMPs are potentially an important tool to prevent the nonmedical use of prescribed controlled substances, their impact is not reflected in drug overdose mortality rates. Their effect on overall consumption of opioids appears to be minimal. PDMP managers need to develop and test ways to improve the use of their data to affect the problem of prescription drug overdoses.

Self-Reported Falls and Fall-Related Injuries Among Persons Aged ≥ 65 Years–United States, 2006 ☆

PROBLEM In 2005, 15,802 persons aged>or=65 years died from fall injuries. How many older adults seek outpatient treatment for minor or moderate fall injuries is unknown. METHOD To estimate the percentage of older adults who fell during the preceding three months, the Centers for Disease Control and Prevention (CDC) analyzed data from two questions about falls included in the 2006 Behavioral Risk Factor Surveillance System (BRFSS) survey. RESULTS Approximately 5.8 million (15.9%) persons aged>or=65 years reported falling at least once during the preceding three months, and 1.8 million (31.3%) of those who fell sustained an injury that resulted in a doctor visit or restricted activity for at least one day. DISCUSSION This report presents the first national estimates of the number and proportion of persons reporting fall-related injuries associated with either doctor visits or restricted activity. SUMMARY The prevalence of falls reinforces the need for broader use of scientifically proven fall-prevention interventions. IMPACT ON INDUSTRY Falls and fall-related injuries represent an enormous burden to individuals, society, and to our health care system. Because the U.S. population is aging, this problem will increase unless we take preventive action by broadly implementing evidence-based fall prevention programs. Such programs could appreciably decrease the incidence and health care costs of fall injuries, as well as greatly improve the quality of life for older adults.

Recent changes in drug poisoning mortality in the United States by urban–rural status and by drug type

This study was conducted to determine how the recently reported increase in drug poisoning mortality rates in the United States varied by degree of urbanization. Although drug poisoning is traditionally seen as an urban problem, evidence suggested that at least one component of the recent increase, deaths involving opioid analgesics, was increasing more rapidly in rural areas.

Trends in opioid analgesic-prescribing rates by specialty, U.S., 2007-2012

INTRODUCTION Opioid analgesic prescriptions are driving trends in drug overdoses, but little is known about prescribing patterns among medical specialties. We conducted this study to examine the opioid-prescribing patterns of the medical specialties over time. METHODS IMS Healths National Prescription Audit (NPA) estimated the annual counts of pharmaceutical prescriptions dispensed in the U.S. during 2007-2012. We grouped NPA prescriber specialty data by practice type for ease of analysis, and measured the distribution of total prescriptions and opioid prescriptions by specialty. We calculated the percentage of all prescriptions dispensed that were opioids, and evaluated changes in that rate by specialty during 2007-2012. The analysis was conducted in 2013. RESULTS In 2012, U.S. pharmacies and long-term care facilities dispensed 4.2 billion prescriptions, 289 million (6.8%) of which were opioids. Primary care specialties accounted for nearly half of all dispensed opioid prescriptions. The rate of opioid prescribing was highest for specialists in pain medicine (48.6%); surgery (36.5%); and physical medicine/rehabilitation (35.5%). The rate of opioid prescribing rose during 2007-2010 but leveled thereafter as most specialties reduced opioid use. The greatest percentage increase in opioid-prescribing rates during 2007-2012 occurred among physical medicine/rehabilitation specialists (+12.0%). The largest percentage drops in opioid-prescribing rates occurred in emergency medicine (-8.9%) and dentistry (-5.7%). CONCLUSIONS The data indicate diverging trends in opioid prescribing among medical specialties in the U.S. during 2007-2012. Engaging the medical specialties individually is critical for continued improvement in the safe and effective treatment of pain.

Prescription drug overdoses: A review

PROBLEM Overdoses involving prescription drugs in the United States have reached epidemic proportions over the past 20 years. METHODS This review categorizes and summarizes literature on the topic dating from the first published reports through 2011 using a traditional epidemiologic model of host, agent, and environment. RESULTS Host factors include male sex, middle age, non-Hispanic white race, low income, and mental health problems. Agent risk factors include use of opioid analgesics and benzodiazepines, high prescribed dosage for opioid analgesics, multiple prescriptions, and multiple prescribers. Environmental factors include rural residence and high community prescribing rates. DISCUSSION The epidemiology of prescription drug overdoses differs from the epidemiology of illicit drug overdoses. Incomplete understanding of prescription overdoses impedes prevention efforts. SUMMARY This epidemic demands additional attention from injury professionals.

What we know, and don't know, about the impact of state policy and systems-level interventions on prescription drug overdose

BACKGROUND Drug overdose deaths have been rising since the early 1990s and is the leading cause of injury death in the United States. Overdose from prescription opioids constitutes a large proportion of this burden. State policy and systems-level interventions have the potential to impact prescription drug misuse and overdose. METHODS We searched the literature to identify evaluations of state policy or systems-level interventions using non-comparative, cross-sectional, before-after, time series, cohort, or comparison group designs or randomized/non-randomized trials. Eligible studies examined intervention effects on provider behavior, patient behavior, and health outcomes. RESULTS Overall study quality is low, with a limited number of time-series or experimental designs. Knowledge and prescribing practices were measured more often than health outcomes (e.g., overdoses). Limitations include lack of baseline data and comparison groups, inadequate statistical testing, small sample sizes, self-reported outcomes, and short-term follow-up. Strategies that reduce inappropriate prescribing and use of multiple providers and focus on overdose response, such as prescription drug monitoring programs, insurer strategies, pain clinic legislation, clinical guidelines, and naloxone distribution programs, are promising. Evidence of improved health outcomes, particularly from safe storage and disposal strategies and patient education, is weak. CONCLUSIONS While important efforts are underway to affect prescriber and patient behavior, data on state policy and systems-level interventions are limited and inconsistent. Improving the evidence base is a critical need so states, regulatory agencies, and organizations can make informed choices about policies and practices that will improve prescribing and use, while protecting patient health.

CDC’s National Violent Death Reporting System: background and methodology

Objectives: This paper describes a new surveillance system called the National Violent Death Reporting System (NVDRS), initiated by the United States Centers for Disease Control and Prevention. NVDRS’s mission is the collection of detailed, timely information on all violent deaths. Design: NVDRS is a population based, active surveillance system designed to obtain a complete census of all resident and occurrent violent deaths. Each state collects information on its own deaths from death certificates, medical examiner/coroner files, law enforcement records, and crime laboratories. Deaths occurring in the same incident are linked. Over 270 data elements can be collected on each incident. Setting: The 13 state health departments of Alaska, Colorado, Georgia, Maryland, Massachusetts, New Jersey, North Carolina, Oklahoma, Oregon, Rhode Island, South Carolina, Virginia, and Wisconsin. Subjects: Cases consist of violent deaths from suicide, homicide, undetermined intent, legal intervention, and unintentional firearm injury. Information is collected on suspects as well as victims. Interventions: None. Outcome measures: The quality of surveillance will be measured in terms of its acceptability, accuracy, sensitivity, timeliness, utility, and cost. Results: The system has just been started. There are no results as yet. Conclusions: NVDRS has achieved enough support to begin data collection efforts in selected states. This system will need to overcome the significant barriers to such a large data collection effort. Its success depends on the use of its data to inform and assess violence prevention efforts. If successful, it will open a new chapter in the use of empirical information to guide public policy around violence in the United States.

A National Epidemic of Unintentional Prescription Opioid Overdose Deaths: How Physicians Can Help Control It

Both the usage of prescription drugs such as opioid analgesics and benzodiazepines and overdoses involving them have increased dramatically in the United States since the 1990s. Patients using these drugs often have a combination of painful conditions, substance abuse, and other forms of mental illness. Psychiatrists and many primary care physicians might not be familiar with existing evidence-based guidelines for opioid prescribing or with programs designed to reduce the abuse of prescription drugs such as state prescription drug monitoring programs. Psychiatrists need to be informed regarding this problem to partner effectively with both pain specialists and primary care providers in their community.