By Columbia Mailman School of Public Health

Controversy surrounds the effects of policies to reduce opioid prescriptions on suicide rates. There are concerns that rapid reductions in prescription opioids might provoke increased suicide risk among people who become desperate after they are taken off opioids. According to a new study at Columbia University Mailman School of Public Health and Columbia University Irving Medical Center, however, changes in regional opioid prescribing and regional suicide rates tend to move in the same direction. This relationship held for rates of opioid prescribing, rates of high-dose prescribing and long-term prescribing, and having multiple opioid prescribers. Until now it was not known whether certain opioid prescribing patterns were associated with particularly elevated suicide risk.

Overall opioid prescribing declined for each of the measures during the 2009–2017 period and the overall rate of total suicide deaths increased from 13.80 to 16.36 per 100,000 persons. By evaluating regional changes, however, the researchers estimate that had opioid prescribing remained constant rather than decreased, the national rate of suicide would have risen even faster than it did.  

The findings are published online in the American Journal of Psychiatry(link is external and opens in a new window).

Alternately, having any opioid prescriptions and having three or more opioid prescribers were each negatively associated with unintentional opioid-related deaths in people in the age ranges of 10- to 24 and 25- to 44. For some opioid prescribing measures, negative associations were also observed with unintentional overdose deaths involving opioids among younger people.

“The relationship between opioid prescribing and suicide risk is a complex one. This is particularly the case when people have their opioids tapered,” said Mark Olfson, MD, MPH, professor of epidemiology at Columbia School of Public Health and Elizabeth K Dollard Professor of Psychiatry, Medicine and Law at Columbia University Irving Medical Center. ”People can become desperate if their pain is not well controlled. “Yet opioids also pose a greater risk of overdose than any other drug class and approximately 40 percent of overdose suicide deaths in the U.S. involve opioids. At a population-level, the national decline in opioid prescribing over last several years appears to have reduced the number of people who died of suicide.”

Analyses were based on data from the 2009–2017 U.S. national IQVIA Longitudinal Prescription Database and National Center for Health Statistics mortality data. Information was based on opioid prescription, with high-dose prescriptions (>120 mg/day morphine equivalents), with long-term prescriptions (>60 consecutive days), and with prescriptions from three or more prescribers. For geographic aggregation, the researchers used states and commuting zones as defined by the U.S. Department of Agriculture.

The researchers looked at opioid prescribing measures for four age groups: 10–24, 25–44, 45–64, and 65 years or older, as well as males and females. Because length of opioid prescribing is strongly associated with persistent opioid use the researchers included a measure of percentage with opioid prescriptions for long-term opioid prescriptions measured at greater then or equal to 60 consecutive days. Also, because of the association between having multiple opioid prescribers and opioid overdose risk, Olfson and colleagues included a multiple prescriber measure as the percentage with three or more opioid prescribers during a year.

Among individuals in the 45- to 64-year age group, change in regional suicide deaths was positively associated with change in regional opioid prescriptions and change in percentage with at least one opioid prescription.  Overall, the association with change in suicide deaths was significantly stronger in the West than in the East or the Midwest.

“If opioid prescribing per capita had held constant from 2009 to 2017, there would have been an estimated 10.5 percent more suicide deaths involving opioids in 2017,” noted Olfson. The corresponding estimated percentage increases in opioid-related suicide deaths were 15 percent, 9 percent, 9 percent, and 19 percent, respectively, for at least one opioid prescription, high-dose prescriptions, long-term prescriptions, and three or more opioid prescribers.

In the U.S., geographic regions with the greatest declines in people filling opioid prescriptions also tended to have the greatest declines in total suicide deaths. Had the national decline in opioid prescriptions between 2009 and 2017 not occurred, there would have been 3 percent more suicide deaths overall in the U.S. according to the research team. For four of five prescribing measures, decreasing regional opioid prescriptions were also related to declining total opioid-related overdose deaths.

“Although the present population-level research cannot establish that opioid prescriptions cause deaths by suicide, the results are consistent with the view that opioid prescription policies and practices should give careful attention to possible connections between prescription opioids and suicide risk,” noted Olfson.

Co-authors are Timothy Waidmann, and Vincent Pancini, Urban Institute, Health Policy Center, Washington, D.C.; Marissa King, University of Pennsylvania; and Michael Schoenbaum, NIMH, Bethesda.

The study was supported by the National Institute on Drug Abuse, grant (DA044981).

The authors report no financial relationships with commercial interests.

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LETTERS SUCCESSFULLY ENCOURAGED CLINICIANS TO CHECK PATIENTS’ PRESCRIBING RECORDS

Researchers reported new findings from a clinical trial of letters to promote safer and better-informed opioid prescribing. The study, which aimed to encourage clinicians to check on patients in a state database before prescribing them opioids, reported significant and durable gains toward this goal. The research will be published in the January issue of the journal Health Affairs.
 
The study enrolled clinicians who prescribed opioids with benzodiazepines or gabapentinoids. Taking these medications together can increase the risk of overdose. The researchers hypothesized that greater use of state prescription monitoring programs (PMPs), which track all prescriptions of these medications, could help clinicians avoid risky prescribing and safeguard their patients’ health. Nearly all states now run PMPs, but many clinicians still do not use them.
 
“PMPs could help clinicians prescribe opioids and other drugs more safely, but these databases will only move the needle if clinicians actually check them,” said Adam Sacarny, PhD of Columbia University Mailman School of Public Health, the study’s lead author. “Our research shows that simple letters can achieve that goal.”
 
To run the trial, the researchers partnered with the Minnesota Board of Pharmacy, which administers the PMP, and Minnesota Management and Budget Agency, which promotes the use of high-quality evidence to improve state decision-making. They enrolled 12,000 clinicians who prescribed opioids with benzodiazepines or opioids with gabapentinoids. 

The clinicians were then randomly assigned to a control group or to receive one of three types of letters: mandate letters focusing a new state requirement to check the PMP before prescribing opioids, information letters about their patients prescribed opioids with benzodiazepines or gabapentinoids, or combined letters that included both messages. The letters were sent in spring 2021.
 
Sacarny and co-authors analyzed the effects of the letters using de-identified data from the PMP. The data included all opioid, benzodiazepine, and gabapentinoid prescriptions dispensed throughout Minnesota, as well as all PMP account records and searches.
 
The researchers found that letters mentioning the mandate to check the PMP successfully increased engagement with the program. PMP search rates rose by 9 percent, and the effect persisted at least 8 months. The letters also encouraged clinicians to make PMP accounts, a prerequisite for searching. Effects were similar for the combined letters, which mentioned the mandate and also included prescribing information.
 
“The enduring impacts suggest that the letters encouraged engagement among clinicians who would not have otherwise created PMP accounts or searched the PMP. This finding is noteworthy because account creation is an important barrier to PMP use,” noted Mireille Jacobson, PhD, the study’s last author and associate professor of Gerontology at the University of Southern California.
 
The researchers note that other state PMPs or healthcare organizations could easily send similar letters as a part of a cost-effective evidence-based strategy to promote safer prescribing. Because the mandate letters contain no protected health information, they could also be sent over e-mail, further lowering the intervention cost.
 
The researchers detected no effects of the information letters, which did not focus on the new mandate to check the PMP. None of the letters led to detectable changes in prescribing.
“While the letters did not make a detectable difference in prescribing, we still think these results are encouraging,” noted Sacarny. “Letters focusing on the mandate successfully promoted PMP engagement through searching and account-holding, which meant clinicians had better access to key patient data as they decided on treatment.”
 
The study’s co-authors are Tatyana Avilova of the University of Tokyo, David Powell of the RAND Corporation, Ian Williamson and Weston Merrick of Minnesota Management and Budget, and Mireille Jacobson of the University of Southern California. 
 
The study was supported by the Abdul Latif Jameel Poverty Action Lab and the National Institute for Health Care Management.

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MEDICATION FOR OPIOID USE DISORDER WAS LOWEST AMONG ADOLESCENTS AND ADULTS AGES 50 AND OLDER

Despite strong evidence that medication is the most effective treatment for opioid use disorder (OUD), adolescents and most adults with a need for OUD treatment reported a lack of medication for OUD in the past year, according to a study by researchers at Columbia University Mailman School of Public Health. Among those who may have needed opioid use treatment, only 28 percent received medication for OUD. Until now, national studies on medication for OUD were lacking. The findings are published in JAMA Network Open.

“Our nationally representative research revealed critical gaps in treatment engagement and use of medication for opioid use disorder. Increased efforts to address barriers to care are critically needed,” said Pia Mauro, PhD, assistant professor of epidemiology at Columbia Mailman School and the study’s lead author. “Evidence supporting the effectiveness of medication for opioid use disorder such as methadone, buprenorphine, or naltrexone is unequivocal, but most people who needed OUD treatment in the U.S did not receive this gold standard treatment.“

The findings were based on data from the 2019 National Survey on Drug Use and Health. Participants were community-based, and data excluded people who were institutionalized or homeless not in shelters. The researchers identified adolescents and adult respondents who may benefit from medication for OUD defined as meeting criteria for a past-year opioid use disorder, reporting past-year medication for OUD, or receiving past-year specialty treatment for opioid use.

The data showed that 57 percent received no treatment for the disorder, and 15 percent received only services without medication. Notably, adolescents (aged 12-17 years) did not receive (medication for opioid use disorder) MOUD in the past year and only 13 percent of adults 50 years and older received medication for the disorder. “Our findings support calls for additional MOUD engagement and retention strategies tailored for both adolescents,” noted Mauro.

Among adults, the likelihood of past-year MOUD receipt compared to no treatment was also lower for people aged 50 years and older, versus for those 18 to 25 years of age. “Our finding that a minority of adults and no adolescents received MOUD indicates substantial gaps in access,” observed Mauro. “These results provide critical evidence to inform national efforts needed to increase equitable access to MOUD.”

Nearly one-third of non-Hispanic white people in need of OUD treatment received medication, compared with approximately 20 percent of people identifying as non-Hispanic Black or multiracial groups and 15 percent of Hispanic people. In contrast, roughly similar proportions of each racial and ethnic group received non-medication services, revealing significant disparities specifically for access to medication treatment among people of color.

MOUD was lower among women, more likely among adults with at least some college, and less likely in small metropolitan areas versus large metropolitan areas. While contacts with the health care system (85 percent) and criminal legal system (61 percent) were common, most people encountering these systems did not report receiving MOUD (30 percent and 39 percent, respectively). 

Starting in 2020, the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act mandated that Medicaid cover all three U.S. Food and Drug Administration–approved medications for OUD, including methadone in certified opioid treatment programs. 


“Policies that expand Medicaid coverage for these medications is an important population-level strategy to potentially increase access to effective opioid use disorder treatment in the publicly insured population,” said Hillary Samples, PhD, assistant professor at the Rutgers School of Public Health and study senior co-author. “In any case, our findings provide further evidence that investments are needed to increase MOUD prescribing and referrals in ambulatory settings.”

Co-authors are Sarah Gutkind and Erin Annunziato, Columbia Mailman School of Public Health.

The study was supported by the National Institute on Drug Abuse (grant numbers DA045224, DA049950, DA031099).  

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LOS ANGELES (AP) — A Los Angeles man was arrested Wednesday on charges that he sold counterfeit opioid pills to Mac Miller two days before the rapper died of an overdose.

Cameron James Pettit, 28, who lives in the Hollywood Hills, is expected to appear in court later Wednesday, federal prosecutors said in a statement.

The 26-year-old Miller, who was known to many as Ariana Grande’s ex-boyfriend but was a respected rapper in his own right, was found dead by his assistant at his San Fernando Valley home on Sept. 7, 2018.

A Drug Enforcement Agency affidavit alleges that Miller asked Pettit for oxycodone and other drugs, but on Sept. 5, 2018, Pettit gave Miller counterfeit oxycodone pills laced with the powerful opioid fentanyl.

An autopsy found that Miller died from an accidental overdose , via a combination of fentanyl, cocaine and alcohol.

Authorities found drugs they believe were from Pettit in Miller’s home, and evidence that Miller had crushed and sniffed oxycodone provided by Pettit.

Pettit has only been charged with providing the drugs, however, and not with having a direct role in Miller’s death. It was not immediately known if he had an attorney, and no relative or associate of Pettit could be found for comment.

After reports of Miller’s death circulated, Pettit sent an Instagram message to a friend saying, “Most likely I will die in jail,” according to the affidavit.

Pettit goes on to write, “I’m gonna get off the grid. Move to another country.”

Investigators also obtained text messages between Miller and Pettit before the sale, in which Miller proclaims his love for oxycodone, or “percs” for the brand name Percocet, and also asks for “bars” of Xanax and a “ball” of cocaine.

“When can u get em?” Miller asks, according to a transcript of the exchange contained in court filings.

“Probably in an hour or 2. They are 30 ea,” Pettit replies.

“Any chance I can get 10 of those, 10 bars and a ball?” Miller asks.

“Yeah for sure,” Pettit replies.

The autopsy report found that Miller had a history of drug and alcohol abuse, but had not previously overdosed or been hospitalized for any reason.

The report notes that Miller’s many tattoos included one of an hourglass on his arm with the words, “Only so much time left in this crazy world.”

Miller’s assistant told investigators he was feeling positive about the projects he was working on, but had a tendency to slip into drug binges.

Miller’s family declined comment on the arrest through a spokesman.

U.S. Attorney Nick Hanna said in a statement after Pettit’s arrest that “Fentanyl disguised as a genuine pharmaceutical is a killer — which is being proven every single day in America.”

The charges were first reported Wednesday by NBC News.

A Pittsburgh native whose real name was Malcolm James Myers McCormick, Miller’s rhymes included frank discussion of his depression and drug use, earning him fans among some of the biggest names in hip-hop.

Performers at a concert in his honor included Chance the Rapper and Travis Scott.

He was also in a two-year relationship with Grande that ended earlier in 2018. After his death she posted an affectionate video of him on her Instagram page and released a song, “Thank U Next,” that lovingly mentions him, saying, “Wish I could say thank you to Malcolm ’cause he was an angel.”

Miller is the latest musician whose death has been linked in recent years to a national wave of opioid abuse and overdoses. Prince died in 2016 when he took counterfeit pills laced with fentanyl that looked like a generic version of the painkiller Vicodin.

Matthew Roberts, guitarist for the band 3 Doors Down, also died of an overdose in 2016, and had fentanyl and hydrocodone in his system.

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