Neil Osterweil

November 12, 2013

BOSTON — Drug poisoning, primarily in the form of overdoses, has supplanted motor vehicle accidents as the leading cause of injury death in the United States. This change occurred with startling speed.

"We see many other leading causes of death declining or staying relatively stable, but in a short amount of time, drug-overdose deaths increased dramatically. In 2005, there were more overdose deaths than motor vehicle crash deaths in 10 states; in 2010, it was 31 states," said Christopher Jones, PharmD, a commander in the US Public Health Service and prescription drug-overdose expert at the US Centers for Disease Control and Prevention (CDC).

The primary driver of the increase is opioid analgesic sales and use, Dr. Jones reported. In 2010, opioid analgesics were attributed to 16,651 deaths, and that class of drug was likely a significant fraction of the 25% of drug deaths in which drug category was not specified.

Dr. Jones discussed this issue here at the American Public Health Association 141st Annual Meeting.

For every death from an opioid overdose in the United States, there are an estimated 15 admissions for abuse treatment, 26 emergency department visits, 115 people who meet the criteria for abuse, and 733 people who take prescription opioids for nonmedical reasons.

The total healthcare-related costs are estimated to be $435 million, Dr. Jones said.

Rates of opioid overdose deaths rose in parallel with opioid sales, and admissions for opioid-abuse treatment, a marker of morbidity, rose in parallel from 1999 to 2010.

 
In a short amount of time, drug-overdose deaths increased dramatically.
 

Data from the Oregon Prescription Drug Monitoring Program indicate that the top 8.1% of providers are responsible for prescribing 79.0% of all US Drug Enforcement Administration (DEA) schedule II to IV drugs.

Similar data come from Ontario, Canada. In 2006, the top 20.0% of family physician prescribers accounted for 72.0% of opioid prescriptions and 63.0% of opioid-related overdose deaths (Can Fam Physician. 2011;57:e92-e96).

In addition, a recent study found that "prescribers with 66 or more patients receiving opioids, who represented 25% of prescribers, prescribed for 82% of all shoppers" (J Opioid Manag. 2012;8:285-291), Dr. Jones noted.

Men are more likely to die from an opioid overdose than women, but women are quickly catching up. The CDC reports that since 1999, prescription painkiller overdoses, as a proportion of all death, have risen by 265% in men but by more than 400% in women.

Other risk factors for opioid overdose death are being 35 to 54 years of age, being white or Native American, being on Medicaid, and living in a rural area. Some clinical characteristics of those who overdose include chronic pain, substance abuse, mental health problems, multiple prescriptions or multiple prescribers, and a high daily dose of opioids.

Combating the Epidemic

The CDC, DEA, and other agencies are working with state governments to address 3 key drivers of the prescription drug overdose problem: increased opioid prescribing; specific providers accounting for most of the inappropriate prescribing; and high-risk patients who engage in abuse and drug diversion and who fly under the radar of the vast majority of scrupulous prescribers.

Dr. Jones cautioned, however, that stricter controls to prevent the inappropriate use of opioids could drive abusers to other illegal options, such as heroin. "If someone is addicted to opioid analgesics, taking away their opioid doesn't take away their addiction," he said.

State-level prescription drug monitoring programs are a powerful tool that clinicians can use to identify prescription-drug shoppers, said Michael Zemaitis, PhD, from the University of Pittsburgh School of Pharmacy.

"Prescription monitoring, which is available in most states, gives you at least a window into what has been going on for the past couple of weeks," he told Medscape Medical News. "If you look up the person and see that he has been to 2 doctors, 3 emergency rooms, and 4 other pharmacies, you have pretty good idea that there might be something going on," he explained.

Another option for reducing overdose deaths is making the narcotic antagonist naloxone more widely available, Dr. Zemaitis noted.

"It's part of every EMT's bag. If they find a person lying on the ground, the first thing they do is give him a shot of naloxone. If it's a heroin overdose, it brings them back quickly; if it's not, it doesn't do any damage," he said.

Pharmacists in Pittsburgh are being equipped and trained to prepare doses of intranasal naloxone for distribution to high-risk patients in drug and pain clinics.

Dr. Zemaitis suggested that parents, friends, or spouses of at-risk drug users could be equipped with emergency supplies of intranasal naloxone, much in the way that people at risk for anaphylactic allergic reactions carry self-injectable epinephrine pens.

Dr. Jones's work is supported by the CDC. Dr. Jones and Dr. Zemaitis have disclosed no relevant financial relationships.

American Public Health Association (APHA) 141st Annual Meeting: Abstract 294943. Presented November 4, 2013.

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