Erin Johnson, MPH, has been the Prescription Pain Medication Program Manager for the Utah Department of Health’s Prescription Pain Medication Management & Education Program since 2007. The Program came into existence as a way to combat the increasing number of prescription pain medication related deaths in the state. This is Ms. Johnson’s third PainEDU interview.

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Questions

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Evelyn Corsini, MSW:

What led to the development of the Prescription Pain Medication Education Program in Utah?

Erin Johnson, MPH: Around the year 2000, the Utah Medical Examiner, Todd C. Grey, MD, whose job it is to examine all unexplained deaths in Utah, found the number of deaths related to drug overdose to be a significant amount of his caseload, most of which involved prescription drugs. Robert Rolfs, MD, MPH, of the Bureau of Epidemiology at the Utah Department of Health, confirmed that the increase was due to prescription drugs, and began investigating.

With this information as a foundation, interested stakeholders began to develop a plan for a statewide program to educate both health care providers and the public about the safe use of prescription pain medication. In 2007, the Utah State Legislature voted to fund the project for two years, setting the goal to decrease the incidence of prescription pain medication related deaths by 15% by the year 2008. There were three specific program objectives:

1. Create written guidelines for health care providers
2. Educate providers, patients, insurance companies and the general public
3. Conduct research about prescription pain medication related deaths

EC: What was the result of these efforts and what is the status of the program now?

EJ: We developed statewide guidelines for health care providers and a number of educational resources and events for clinicians and the public. This included a statewide media campaign as well as the launch of an educational website called useonlyasdirected.org. We targeted adults between the ages of 25 – 54, because this age group accounts for the majority of prescription overdose deaths in Utah.

In 2008, we were pleased to see a 12.6% reduction in the number of prescription pain medication related deaths. Unfortunately, the grant ended, and the number of deaths increased again in 2009. We believe that deaths dropped because we hit the problem hard that first year while we had funding for education. In order to maintain this drop and make prescription drug safety common knowledge the education needs to continue over time. Most prevention experts say that it takes a sustained effort over ten years to change behavior patterns. The website will remain up for at least the next 7 years, and we have received grants from private foundations to continue some of our research efforts.

EC: Describe the “virtual autopsies”.

EJ: We knew that the controlled substances and death certificate databases did not tell the whole story. Just knowing that a citizen of Utah received a prescription for a pain medication within 30 days of their death did not tell us enough. We wanted to understand the factors involved that may predispose someone using a prescription opioid to have a fatal overdose.

In order to identify characteristics related to unintentional (accidental and undetermined intent) drug overdose deaths, we interviewed the relative or friend who was most knowledgeable about the deceased person’s life. We looked at Utah residents, ages 12 and older, who had died between 10/26/08 and 10/25/09. Of the cases seen by the Medical Examiner during this time, 432 were drug overdose deaths.

EC: What did you learn from the virtual autopsies?

EJ: The majority of the drug overdose deaths (64%, N=278) involved at least one opioid medication. Of these, 240 included an opioid with no illicit drugs. The other 38 had used an opioid with at least one illicit drug.

We successfully conducted interviews of about 385 of these 432 cases. We were very pleased to achieve this 90% response rate. The interviews were often very long and we are very grateful for the (mainly) willing participants who spent time helping us learn about their loved ones. We asked questions about whether the decedent was dabbling in other drugs, or was taking more than prescribed. Overdose deaths involving only illicit drugs were most common from ages 18 to 44. Overdose deaths involving non-illicit drugs were most common from ages 25 to 54.

Of the 240 opioid-related, non-illicit drug overdose deaths, 51% were male, and 78% were ages 25 – 54. The family members and friends we interviewed reported that 83% of these people suffered from chronic pain. We found three characteristics that appeared to be strongly correlated to the overdose deaths.

Financial problems

• 63% were unemployed during the last two months of their life.
• 59% of the respondents reported that the decedent had a financial problem during the two months prior to their death.

Past history of substance abuse

• When asked if the decedent experienced a substance abuse problem during the two months prior to death, 40% responded “yes”.
• 49% of decedents had received treatment for substance abuse at some time in their life.
• 50% of decedents smoked daily before their death.

Mental stability

• 49% of the decedents were reported to have been diagnosed with a mental illness by a healthcare provider. The primary diagnosis was depression.
• 24% had been hospitalized for a psychiatric reason.

EC: Will you be publishing your findings, and what do you hope will be gained by this?

EJ: We are in the process of writing up the results for several publications. We hope that by understanding more about the lives of these people, who died of a medication that was prescribed for them by a health care provider whose goal was to help them, we will educate health care providers and families to be more aware of risk factors that can be an early warning signal.