Overdose Overdose among VA patie

patie

receiving opioid therapy for 

Risk factors and preventio

Amy S.B. Bohnert, Ph.D.

Affiliations:

VA National Serious Mental Illness Treatment Resource & Evaluat

VA Ann Arbor HSR&D Center of Excellence, Center for Clinical Manage

University Univ sity er of Michigan Medical School, School, Departmen Department of Psych

Psych
Acknowledgements

Supported b

y f d un

ding

from Veteran Heal ht

h

A

dministra

of Mental Health Operations and VA HSR&D grant CD

NIH grant R03 AG042899 AG042899, and the University University of M

M

Department of Psychiatry and Injury Cente

No conflicts of interest to report.

Outline

Objective: To describe strategies for re

risk of opioid overdose for VA patien

pain.

1. Research on trends and risk factors

2. Potential settings for intervention

3. Prevention stt i ra eg es, quality of evid
Use of Prescription Prescription Opioids Opioids in t

Prescription Opioids: pain medications that contain opioids (naturally o

synth i ) d i i i i h U S i l di d i 

hetic) and require a prescription in the U.S., including codeine, percoc

Non‐Medical/

Extramedical Use

Pain Treatment

Extramedical Use
1. Overdose Overdose Epidemiolog

Epidemiolog

• Trends Over Time

• Risk Factors
Poisoning/Overdose Mortality R

the U.S.
Comparison to Other Majo

Unintentional Injury Causes of 
Non‐Fatal Poisoning/Overdose 

U.S.
Opioid Analgesics: Sales an

Overdoses

S M d 

ource: Medsc
Overdose Rates are Elevated A

VA Patients

U.S. 2005 V.H.A. FY2005

Gender/

Age Group

Accidental

Poisonings

Crude Rate

per 100,000

person‐years

Accidental

Poisonings

Crude Rate

per 100,000

person‐years

Standa

Mort

Rat

Males 15,679 14.51 960 20.62 1.9

18‐29 yrs 3,390 13.45 28 21.86 1.630‐64 yrs 11,826 17.53 841 36.81 2.1

65+ yrs 463 3.01 91 4.06 1.3

Females 7,647 6.68 53 11.82 1.6

18‐29 yrs 1,024 4.28 1 1.70 n/

30‐64 yrs 6,155 8.91 50 15.34 1.7

65+ yrs 468 2.19 2 3.14 n/

Total 23,326 10.49 1,013 19.85 1.9

From Bohnert, Ilgen, Galea, et al., 
Risk Factors Factors Among Pain Pa

Pa

• Opioid Dose (prescribed or amount fil
Risk of Opioid Overdose Among VA Patients, Prescribed 

From Bohnert, Valenstein, Bair et al
Opioid Dose and Overdose in Chroni

Patients

Bohnert et al.: VA Patients (national sample)Dunn et al.: Group Health Cooperative (Washington state)
Risk Factors Factors Among Pain Pa

Pa

• Opioid Dose

• Opioid Schedule Schedule (but confounded confounded by d
Unadjusted Overdose Rates by Prescribing Cha

From Bohnert, Valenstein, Bair et 
Risk Factors Factors Among Pain Pa

Pa

• Opioid Dose

• Opioid Schedule

• Opioid Type? (limited evidence)
Opioid Type

• Paulozzi et al. Pain Med 2012

– Case‐control study of New Mexico drug overdo

• Research to date has not accounted for patient sel

factors.

– Note: Krebs et al., 2011 found lower all‐cause mortality for methadone than 

propensity score adjustment
Risk Factors Factors Among Pain Pa

Pa

• Opioid Dose

• Opioid Schedule

• Demographic Characteristics
Demographic Characterist

From Bohnert, Valenstein, Bair et a
Risk Factors Factors Among Pain Pa

Pa

• Opioid Dose

• Opioid Schedule

• Demographic Characteristics

• Pain Diagnosis and Co‐morbidity

– Pain Type– Substance use disorders– Other ment l a h lth ea conditions
Unadjusted Association of Pat

Pat

Characteristics with Unintentional Unintentional O

O

Opioid Overdose Opioid Overdose 

Decedents, 

N = 750 

n (%) 

All Others, 

N = 154,684 

n (%) 

Pain-Related Diagnoses

 Cancer 91 (12.1) 36,712 (23.7

Ch i B dil P i Chronic Bodily Pain 588 (78 4) 588 (78.4) 107 158 (69 3

107,158 (69.3

 Headache 90 (12.0) 10,208 (6.6) 

 Neuropathy 32 (4.3) 8,339 (5.4) 

 Injuries and Acute Pain 222 (29.6) 29,522 (19.1

Other Diagnoses

 Substance Use Disorders 296 (39.5) 15,195 (9.8) 

 Other Psychiatric Disorders 498 (66.4) 51,929 (33.6

 COPD, CVD, and/or Sleep Apnea 467 (62.3) 123,025 (79.5

From Bohnert, Valenstein, Bair et al
Risk Factors Factors Among Pain Pa

Pa

• Opioid Dose

• Opioid Schedule

• Demographic Characteristics

• Pain Diagnosis and Co‐morbidity

• “Doctor Shopping Shopping” and Other Behavio

Behavio

Factors
–

“Doctor Shopping”

• Peirce, Peirce, Smith, Abate, Halverson Halverson Med Care 2

– Case‐control study in West Virginia of drug‐rela– Doctor shopping shopping (DS): 3+ doctors doctors prescribe prescribe in 6 – Pharmacy shopping (PS): 4+ pharmacies in 6 m

Odds Ratio 95% CI

No DS, No PS 1.0 ‐‐

Adj 

DS, no PS 2.03 1.60 – 2.57

PS, no DS 3.18 2.25 – 4.48

Both DS and PS 3 60 2 74 4 73

Adj

type 

• Little research on behavioral factors other t

i di t f bl ti

Both DS and PS 3.60 2.74 – 4.73

severe indicators of problematic use
Risk Factors Factors Among Pain Pa

Pa

• O i id p o Dose

• Opioid Schedule Medicatio

• Opioid Type?

• Demographic Characteristics

• Pain Diagnosis and Co‐morbidity• Bh i e av oral F t ac ors P

Little research on provider characteristic

setting, health system characteristi
Methodological Limitations of 

Factor Research

• Cautions of observational healthc

data

• Challenges in studying rare event

as overdose
2. VA Clinic Setting Setting and Ove

Ove

• In progress work

• Retrospective Retrospective study of types of clinics clinics 

prior to death for VA patients who dieprescription opioid overdose

• Objective to identify clinical settings w

opportunities to intervene with patien

risk for ov dose overdose exist
Methods

• Retrospective, descriptive analysis• Sample: Sample: all unintentional unintentional opioid overd

overd

decedents, FY04‐FY07

– L t as vi it s was out ti pa ent– Contact with VHA in last two years befor

– N = 985
Outpatient Treatment Received Prior to Unintentional Opioid Overdose 

Death 

N 

Overall – Any Treatment or Contact Any Treatment or Contact 

N 

7 days prior 277 

30 days prior 557 

1 year prior 903 

Categories of Treatment Any Substance Abuse (SA) 

Treatment 

7 days prior 16 

30 days prior 30 days prior 50 

1 year prior 200 

Any Mental Health Treatment (no SA) 

7 days prior 7 days prior 86 

30 days prior 214 

1 year prior 538 

Any Mental Health or SA Treatment 

7 days prior 7 days prior 98 

30 days prior 242 

1 year prior 566 

Pain Clinic Treatment 

7 days prior 7 days prior 10 

30 days prior 23 

1 year prior 97 

Primary Care (PC) Treatment 

7d i 

days prior 96 

30 days prior 269 

1 year prior 752 
Implications

• Over half had been seen in the prior 3• Primary care and mental health clinic 

common and interventions in these se

may have a greater greater impact
3. Overdose Prevention in P

Treatment Settings
Prevention of Prescription Op

Overdose in the U.S.

Non‐Medical/

Extra‐Medical Use

Pain Treatment

Strategies: 

-Patient selection -Prescription drug monitoring systems -Universal preventio

Universal preventio

-Prescribing practices -Har-Patient and caregiver education -Naloxone Distribution? -Monitoring 
Patient Selection

• DoD/VA Opioid Guidelines 2010

– Contraindicated for patients:

• With severe respiratory instability• With acute psychiatric psychiatric instability/suicide instability/suicide risk• Who have a substance use disorder (if not in 

• On medications medications with life‐limiting limiting interaction interaction 

• Who actively divert meds

• With an allergy allergy, intolerance intolerance or lack of positiv

positiv

to opioids
Prescription Drug Monitori

Programs

• PDMPs: State‐level registries of pharm

records of certain controlled substanc

on providers to check and alter prescr

behavior if evidence of “doctor shopp

• Evidence: has not impacted overdose 

observational evaluation (Paulozzi, Kil

Desai, Pain Med 2011)

• Inconsistent Inconsistent implementation implementation has likely 

impact
Prescribing Practices

• Some evidence evidence from observational observational stu

stu

that limiting the use of very high dose

reduce risk of overdose overdose

• NOTE: no research has formally tested 

impact of dose limits or compared compared ou

ou

among patients randomized to dose

Patient Patient and Caregiver Caregiver Educa

Educa

• Strength of Evidence: has not been stu

a randomized controlled trial
Monitoring

Monitoring recommendations from DoDguidelines (2010):• Assess for adherence and misuse at ev• Random urine drug screens

• Evaluate for adverse effects

• Consider on‐going evaluation of poten

drug‐drug i t n eractions
Naloxone Distribution

• Naloxone is used to reverse opioid ove

evidence based in medical settings

• Exi i st ng community‐based programs h

distributed naloxone to trained layper(needle exchange participants)

– For examples, see: Seal et al., 2005; Doe‐Simkins et al., 2

naloxone); Tobin et al., 2008; Markham Piper et al., 2008
Naloxone Distribution in Med

Settings

• Adaptation to pain care setting focuse

training caregiver

• Strength of Evidence: feasibility estab

(Project Lazarus – Albert, Branson, Sanal., 2011), no studies of efficacy/effect
Thank you for attending attending this We

We

Questions?

• Contact

– Amy.Bohnert@va.gov– 734‐845‐3638
References

Albert S, Brason FW, 2nd, Sanford Sanford CK, Dasgupta Dasgupta N, Graham J, Lovette Lovette B

Lazarus: community‐based overdose prevention in rural North Carolina

2011;12 Suppl 2:S77‐85.

Bohnert AS, Ilgen MA, Galea S, McCarthy JF, Blow FC. Accidental poison

among patients in the Department of Veterans Affairs Health System. M

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Bohnert AS, Valenstein M, Bair MJ, et al. Association between opioid p

patterns and opioid overdose‐related deaths. JAMA. Apr 6 2011;305(13

Doe‐Simkins Simkins M, Walley AY, Epstein Epstein A, Moyer P. Saved by the nose: bysta

bysta

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References

Krebs EE, Becker WC, Zerzan J, Bair MJ, McCoy K, Hui S. Comparative Comparative m

m

Department of Veterans Affairs patients prescribed methadone or long

morphine for chronic pain. Pain. Aug 2011;152(8):1789‐1795.

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responsibility. JAMA. Dec 10 2008;300(22):2672‐2673.

Paulozzi Paulozzi LJ, Kilbourne Kilbourne EM, Desai HA. Prescription Prescription drug monitoring monitoring prog

prog

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Paulozzi Paulozzi LJ, Kilbourne Kilbourne EM, Shah NG, et al. A history history of being prescribed prescribed 

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Peirce GL, Smith MJ, Abate MA, Halverson J. Doctor and pharmacy sho

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References

Seal KH, Thawley Thawley R, Gee L, et al. Naloxone Naloxone distribution distribution and cardiopulm

cardiopulm

resuscitation training for injection drug users to prevent heroin overdo

intervention study. J Urban Health. Jun 2005;82(2):303‐311.

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