Medscape: Dr. Weisler, can you comment on the age distribution of patients dying from unintentional drug overdoses? It's not exactly what you would expect, is it?
Dr. Weisler: Up to age 14, and there really doesn't appear to be a major risk, although there is always some risk for toddlers and young children accidentally getting a hold of these medications. However, when you look at percentages, it's the 45- to 54-year-olds who are in the greatest risk, followed by the 35- to 44-year-old range. Not very far behind would be the 25- to 34-year-olds; the teenagers, the 15- to 24-year-olds; followed by the 55- to 64-year-olds. Men die at higher rates than women of unintentional drug poisoning, but the rate of death for women is increasing even faster than that for men.
However, I can tell you that I have personally dealt with families who've lost loved ones who were in their late teens or early 20s to accidental, unintentional drug poisonings. Ashwin, I think you've had the same experience?
Dr. Patkar: Yes, in terms of the mortality rates being the highest in the 40- to 50-year-old group. However, I have also seen mortality in earlier age groups, especially the late teens and early 20s.
Medscape: Do we know how many of these patients are intentionally misusing or abusing these drugs, and how many just don't know how to use them and are innocently overdosing?
Dr. Paulozzi: We have some data on that from the mortality studies that have been done in a few states. The CDC conducted a study in West Virginia on drug overdose deaths in 2006. We looked at the prevalence of a variety of risk factors that might have indicated nonmedical use of opioids when we looked just at the subset of prescription drug-related deaths; in other words, we separated out the deaths that were related to illicit drugs.
In that group, about 78% had a history of substance abuse, whether it was alcohol or drugs, when the medical examiner investigated their medical and social histories. Sixty-three percent of the deaths had at least 1 drug in their system at the time of death for which they had no prescription, and about 22% used a nonmedical route of administration, meaning that they crushed their oxycodone (OxyContin®), for example, and injected it or snorted it.
Twenty-one percent had seen 5 or more doctors for controlled substances in the past year. All told about 95% of the deaths had one of these signs suggestive of nonmedical or abusive use. This is not to say the people didn't also have pain, and perhaps many of them started taking the drugs for pain. They had, however, in almost all of the cases, moved into a way of using the drugs that was definitely not as prescribed.
Dr. Weisler: Not to pick on Ohio -- but the Ohio Department of Health did a really nice job looking at this recently. They had 4.8 million prescriptions for hydrocodone, and there are only about 11.5 million people in the state, so that means that 1 in every 2.5 people in the state of Ohio got a prescription for hydrocodone in 2008; 2.7 million prescriptions in 2008 in Ohio, or 1 for nearly every 4 people, were for oxycodone. With this kind of prescribing pattern, it's not too hard for someone to gain access to these pills, and, quite honestly, there is a lot of money in it for some people. The price of the drug in the drugstore may be one tenth of what the street price would be, I am told. Do you agree, Ashwin?
Dr. Patkar: Oxycodone is roughly 75 cents to $1 a milligram in North Carolina, so an 80-mg pill can be purchased for $60-$80.
Dr. Weisler: Again, a 100-tablet bottle of 80 mg oxycodone in a pharmacy without insurance would cost approximately $750, according to DrugStory Factsheet: Abuse of Prescription Painkillers. When you do the math, like Ashwin just did, and multiply 100 times $60-$80, you end up with a lot of money.
When I looked around the country, the unintentional poisoning death rates appear to be the highest where the poverty level is higher. I don't know whether poverty is what drives it, or unemployment perhaps?
Dr. Paulozzi: Yes, in West Virginia there was a significant association between the rate of drug death and the percentage of the population in the county below the poverty level. In an investigation that was reported in Morbidity and Mortality Weekly Report (MMWR), we saw that people who were enrolled in the Medicaid program in Washington State were about 6 times more likely to die of a prescription opioid-related overdose death than people not in the Medicaid program.
Dr. Weisler: Yes, and in that same article a group of patients in the Medicaid population who got even more review and attention still had the highest unintentional poisoning death rate. Correct?
Dr. Paulozzi: Yes. Most states have a Medicaid patient restriction and review program that's sometimes colloquially called a "lock-in" program. The program identifies, through its records, individuals who may be doctor shopping or getting overlapping prescriptions. They enroll those people in programs where they can see 1 provider and 1 pharmacist for their controlled substances. In Washington State, that group was still something like 90 times more likely to die of an overdose death than people who weren't in Medicaid.
Dr. Weisler: One other thing that I've noticed in looking at the available data is that in some of the states where people live near borders -- where they can easily access other states -- residents tend to have higher overdose rates. The prescription drug monitoring programs, at the moment, only report data from their own state's pharmacies. Therefore, if you practice, for example, in Ohio, you wouldn't see the Kentucky data or the West Virginia data unless you are registered in more than 1 state. The patients who might be doctor shopping may deliberately go across state lines for their care; therefore, it would be much harder to track their controlled drug prescriptions.
That said, I have found the prescription drug monitoring program for controlled substances extremely useful. It's relatively easy to register for, and you can easily access which medications your patients are getting, what providers they are seeing, and what pharmacies they are using. Scheduled-drug misuse may be deliberate at times, but adverse outcomes can also occur due to medication error as a result of being forgetful or distracted.
Len, you mentioned benzodiazepines earlier. In Florida, I believe that 705 people were listed by the medical examiner as having died in 2008 from alprazolam. Death due to alprazolam alone occurred in 12 cases out of 705 deceased persons for whom alprazolam contributed to their deaths. However, when alprazolam and other benzodiazepines often used for anxiety and sleep were taken in combination with opiates, other pain medications, or alcohol, the death rate was much higher.
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Cite this: Unintentional Drug Poisoning Deaths: A National Epidemic - Medscape - Jun 28, 2010.