Transcript Clement 2014

Presenters:
Cassandra Clement, Pharm.D., BCPS
Orlando VA Medical Center
Orlando, Florida
Chris Stock, Pharm.D., BCPP
George E. Wahlen Department of Veterans Affairs Medical Center
Salt Lake City, Utah
IRB Status:
Exempt Status Approved
Co-investigators:
Christopher Stock, Pharm.D., BCPP
Conflicts of Interest: None
Project Sponsorship: None
Also referred to as Salt
Lake City Veterans
Affairs Medical Center
(SLC VAMC)
121 bed hospital
9 Community-Based
Outpatient Clinics
Average 64 ED visits
per day
Serves > 50,000 veterans
Opioid overdose deaths continue to be an increasing problem
throughout the United States and within Utah.1
Utah is the eighth highest drug overdose mortality rate in the United
States (16.9 per 100,000)
Some of the risk factors for overdoses have been delineated.3,4
Age
• Middle-aged (overdose death)
• Young or elderly (overdose)
White race
Medical diagnoses
• Chronic or acute pain (versus pain due to
cancer)
• Sleep Apnea
• Morbid obesity
• Preexisting pulmonary or cardiac disease
or dysfunction or major organ failure
Psychiatric diagnoses
• Substance use disorders
• Psychiatric disorders
Medications
• Opioid dose
• >50mg, >100mg, and >200mg
morphine equivalents
• CNS depressants (i.e. anxiolytics,
sedatives)
1.Prescription Drug Abuse: Strategies to Stop the Epidemic. Trust for America's Health. October 2013.
2.ASB Bohnert et al. Unintentional overdose and suicide among substance users: A review of overlap and risk factors. Drug and Alcohol
Dependence 110 (2010) 183–192.
3.Safe use of opioids in hospitals. The Joint Commission. Sentinel Event Alert. Issue 49, August 8, 2012.
4.ASB Bohnert, et. Al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA, 2011.
The veteran population has nearly twice the rate of fatal
accidental poisoning compared with adults in the general US
population
Opioid medications and cocaine were frequently mentioned as the
agents causing poisoning on death records
More detailed information about veterans experiencing
overdose would help to tailor preventative efforts in this
population.
1.ASB Bohnert, et. al Accidental Poisoning Mortality Among Patients in the Department of Veterans Affairs Health System. Med Care
2011;49: 393–396.
2.ASB Bohnert, et. al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA, 2011.
3.Gomes T, et al. Opioid Dose and Drug-Related Mortality in Patients With Nonmalignant Pain. Arch Intern Med. 2011;171(7):686-691.
To describe veterans who received naloxone rescue
therapy for opioid overdose and identify risk factors
within this population such as:
Demographic information
Diagnoses
Prescription accessibility of opioids and
benzodiazepines on the day of and within 120
days of naloxone rescue therapy
Urine drug screen results within 120 days of
naloxone recue therapy
Data collection
Extracted from the VA Data Warehouse
Retrospective open chart review
Reviewed veterans who received naloxone rescue
therapy at the SLC VAMC emergency department (ED)
for opioid overdose between 1/1/2009 and 1/1/2013
Tabulations were made using Microsoft® Excel
Information collected:
Naloxone rescue therapy
(ED visit date)
Demographic information
Diagnoses
Sleep apnea, sleep disorders,
obesity, cardiac disease,
pulmonary disease, mental health
diagnoses, and/or substance use
disorder
Prescriptions accessibility within
120 days and on the day of the
ED visit:
Morphine equivalents daily (MED)
Lorazepam equivalents daily (LED)
Urine drug screen (UDS) results
Visits stratified by accessibility to:
Opioids (OPs) only
Benzodiazepines (BZs) only
OPs & BZs
No OPs or BZs
Non-VA documented
prescriptions only
Day of naloxone
therapy
Within 120 days prior to
naloxone therapy
170 veterans
received naloxone
92
Indication:
OP overdose
39
0
28
19
6
OP only
BZ only
OP & BZ
No OP or BZ
Non-VA only
34
4
19
19
6
OP only
BZ only
OP & BZ
No OP or BZ
Non-VA only
Opioid
MED (mg)4
Codeine
Fentanyl
Hydrocodone
Hydromorphone
Methadone
Oxycodone
Tramadol
0.15
3600
1
4
4.5
1.5
0.2
Accessibility
within 120 days of
rescue therapy
(n=92)
Accessibility on
day of rescue
therapy
(n=82)
Benzodiazepine LED (mg)5
Alprazolam
Clonazepam
Diazepam
Lorazepam
Temazepam
0.5
0.25
5
1
5
4. Washington State Agency Medical Directors' Group Second Reference. Online Available: http://agencymeddirectors.wa.gov
5. Lexi-Comp OnlineTM , Benzodiazepine Comparison Table, Hudson, Ohio: Lexi-Comp, Inc.; April 16, 2014.
Opioid daily dose accessible within 120 days of ED visit
900
p value = 0.015
Max = 830mg
800
700
MED (mg)
600
500
Max = 525mg
400
300
Average
259mg
200
100
Average
118mg
0
OP Only
Min = 7.5mg
Min = 15mg
OP & BZ
Opioid daily doses accessible on the day of ED visit
900
800
Max = 830mg
p value = 0.283
700
Max = 650mg
MED (mg)
600
500
400
300
Average
183mg
200
100
0
Average
126mg
OP Only
Min = 20mg
Min = 7.5mg
OP & BZ
Characteristic
OP only
(n=34)
OP and BZ
(n=19)
No OP or BZ
(n=19)
BZ only
(n=4)
Non-VA OP
(n=6)
Mean Age (yrs)
64.4
56.4
62.5
51
75.2
p=0.08
Average days from
last OP prescription
pick-up
19
21
n/a
n/a
n/a
Weekend ED visit
32%
44%
21%
0%
0%
Other person lives at
same address
84%
37%
26%
25%
33%
Characteristic
OP only
(n=34)
OP and BZ
(n=19)
No OP or BZ
(n=19)
BZ only
(n=4)
Non-VA OP
(n=6)
Had > 1 UDS
within 120 days
60%
84%
63%
75%
33%
UDSs reflective of
prescribed
regimens
40%
42%
21%
0%
17%
MED difference of
those who has
reflective UDS vs.
non-reflective
4.2mg*
44mg*
n/a
n/a
n/a
p > 0.5
p > 0.5
Characteristic
OP only
(n=34)
OP and BZ No OP or
(n=19)
BZ (n=19)
BZ only
(n=4)
Non-VA
OP (n=6)
Total
(N=82)
Morbid obesity
9%
26%
5%
25%
33%
15%
Sleep apnea
47%
42%
11%
50%
33%
37%
Sleep disorder
3%
11%
5%
0%
50%
9%
CV disorder
91%
90%
63%
75%
100%
84%
COPD
65%
53%
37%
50%
50%
54%
Cancer
56%
42%
32%
25%
67%
46%
Psychiatric
disorder
74%
89%
79%
100%
50%
78%
CV disorder > Psychiatric disorder > SUD > COPD > Cancer > Sleep apnea > Morbid obesity
Characteristic
OP only
(n=34)
OP and BZ
(n=19)
No OP or BZ
(n=19)
BZ only
(n=4)
Non-VA OP
(n=6)
Tobacco UD
21%
26%
11%
50%
0%
Alcohol UD
26%
11%
16%
0%
0%
Sedative UD
0%
0%
5%
0%
0%
Opioid UD
0%
0%
0%
0%
0%
• 54 veterans (58.7%) had a substance use disorder (SUD)
• None of the veterans had a history of opioid use disorder or dependence
CV disorder > Psychiatric disorder > SUD > COPD > Cancer > Sleep apnea > Morbid obesity
Demographic Information
The average age in our sample was 62, which is consistent with
literature regarding age risk factors.
Prescribed Medications
The ED visit date was not immediately proximate to the last OP
prescription pick-up date
VA’s current opioid safety guidelines6 target > 200mg MED as
the “high risk” dose but this would not capture most of the
veterans in the OP only group.
Veterans prescribed OPs & BZs concomitantly constitutes 23%
of those who required naloxone rescue therapy.
VHA Memorandum April 2, 2014.
Comorbidities
Cardiovascular diagnoses and psychiatric disorders were more
prevalent than SUD, which is not consistent with previously
published risk factor literature.
Urine Drug Screens
68% of veterans prescribed OPs and/or BZs had no documented
UDSs within 120 days prior to the ED visit date
58% of the UDSs were not reflective of prescribed regimens
which may indicate many veterans have aberrant behaviors
which are associated with overdose risk
VHA Memorandum April 2, 2014.
Contact Information:
Cassandra Clement, Pharm.D., BCPS
[email protected]
Christopher Stock, Pharm.D., BCPP
[email protected]