Root cause analysis of prescription opioid overdoses

Kelly M. Wawrzyniak, PsyD; Alex Sabo, MD; Ann McDonald, RN, MN; Jeremiah J. Trudeau, PhD; Mon Poulose, MD; Mary Brown, PhD; Nathaniel P. Katz, MD, MS

doi:10.5055/jom.2015.0262

Authors

Kelly M. Wawrzyniak, PsyD
Alex Sabo, MD
Ann McDonald, RN, MN
Jeremiah J. Trudeau, PhD
Mon Poulose, MD
Mary Brown, PhD
Nathaniel P. Katz, MD, MS

DOI:

https://doi.org/10.5055/jom.2015.0262

Keywords:

root cause analysis, prescription opioids, accidental overdose, polypharmacy, informants

Abstract

Overdoses (ODs) of prescription opioids (RxOs) have become a major public health issue in the United States.

Objective: To determine the root causes of accidental prescription opioid overdoses (RxO-OD).

Design/setting/participants/intervention: The authors conducted a root cause analysis using the Antecedent Target-Measurement method, interviewing three types of key informants: survivors of RxO-ODs, family members, and clinical experts.

Results: Ten survivors, five family members, and three experts were interviewed. Proximal causes of RxO-ODs described by survivors and family members were recent RxO dose escalation (n = 9), polysubstance use (n = 5), and polypharmacy use (n = 3). Proximal causes were elicited by the following six antecedent causes: wanting to feel good/high (n = 9), perceived tolerance to RxO (n = 6), didn't know/believe it was dangerous (n = 5), wanting to reduce psychosocial pain (n = 5), wanting to reduce physical pain (n = 4), and wanting to avoid discomfort due to withdrawal symptoms (n = 4). RxOs involved in the OD were either prescribed by a doctor (n = 7), purchased from a dealer (n = 6), given/purchased from family/friends (n = 3), or stolen from family (n = 1). Psychosocial stressors (n = 9), chronic recurrent depression (n = 3), and chronic substance abuse/addiction (n = 4) were also distal and proximal causes of OD. Experts cited similar causes but added prescriberrelated causes (eg, inadequate training) and healthcare system and culture.

Conclusions: Patients at risk for OD can be identified and ODs potentially prevented. Opportunities for intervention include routine screening of patients using RxOs for psychosocial distress and coping, flagging of high-risk patients, care pathways for high-risk patients, clinician and patient training on OD prevention, and developing abuse-deterrent formulations of RxOs.

Author Biographies

Kelly M. Wawrzyniak, PsyD

Analgesic Solutions, Natick, Massachusetts currently at Boston PainCare, Waltham, Massachusetts

Alex Sabo, MD

Berkshire Medical Center, College of Human Medicine, Michigan State University, East Lansing, Michigan.

Ann McDonald, RN, MN

Berkshire Medical Center, College of Human Medicine, Michigan State University, East Lansing, Michigan.

Jeremiah J. Trudeau, PhD

Analgesic Solutions, Natick, Massachusetts

Mon Poulose, MD

Berkshire Medical Center, College of Human Medicine, Michigan State University, East Lansing, Michigan

Mary Brown, PhD

Department of Pharmacy Practice & Science, College of Pharmacy, University of Arizona, Tucson, Arizona.

Nathaniel P. Katz, MD, MS

Analgesic Solutions, Natick, Massachusetts

References

Centers for Disease Control (CDC): Prescription Drug Overdose in the United States: Fact Sheet. Available at http://www.cdc.gov/homeandrecreationalsafety/overdose/facts.html. Accessed November 25, 2014.

Jones CM, Mack KA, Paulozzi LJ: Pharmaceutical overdose deaths, United States, 2010. JAMA. 2013; 309(7): 657-659.

Substance Abuse and Mental Health Services Administration, Drug Abuse Warning Network: National Estimates of Drug-Related Emergency Department Visits 2004-2011 [Web site data]. 2012. Available at http://www.samhsa.gov/data/emergency-department-data-dawn/reports?tab=28. Accessed November 25, 2014.

Wu AW, Lipshutz AK, Pronovost PJ: Effectiveness and efficiency of root cause analysis in medicine. JAMA. 2008; 299(6): 685-687.

Paulozzi LJ: Prescription drug overdoses: A review. J Safety Res. 2012; 43(4): 283-289.

Lee A, Mills PD, Neily J, et al.: Root cause analysis of serious adverse events among older patients in the Veterans Health Administration. Jt Comm J Qual Patient Saf. 2014; 40(6): 253-262.

Webster LR, Cochella S, Dasgupta N, et al.: An analysis of the root causes for opioid-related overdose deaths in the United States. Pain Med. 2011; 12(suppl 2): S26-S35.

Brown M, Frost R, Ko Y, et al.: Diagramming patients’ views of root causes of adverse drug events in ambulatory care: An online tool for planning education and research. Patient Educ Couns. 2006; 62(3): 302-315.

Van der Schaaf TW, Habraken MMP: PRISMA-Medical: A Brief Description. Eindhoven: Eindhoven University of Technology, Faculty of Technology Management, Patient Safety Systems, August 2005. Available at http://www.who.int/patientsafety/taxonomy/PRISMA_Medical.pdf. Accessed March 31, 2015.

Renger R: A three-step approach to teaching logic models. Am J Eval. 2002; 23(4): 493-503.

Rigg KK, Ibañez GE: Motivations for non-medical prescription drug use: A mixed methods analysis. J Subst Abuse Treat. 2010; 39(3): 236-247.

The Partnership Attitude Tracking Study (PATS): Teens 2007 Report. August 4, 2008. Available at http://www.drugfree.org/wp-content/uploads/2011/04/PATS-Teens-2007-Full-Report.pdf. Accessed January 9, 2012.

Webster LR, Fine PG: Approaches to improve pain relief while minimizing opioid abuse liability. J Pain. 2010; 11(7): 602-611.

Webster L, St Marie B, McCarberg B, et al.: Current status and evolving role of abuse-deterrent opioids in managing patients with chronic pain. J Opioid Manag. 2011; 7(3): 235-245.

Akbik H, Butler SF, Budman SH, et al.: Validation and clinical application of the Screener and Opioid Assessment for Patients with Pain (SOAPP). J Pain Symptom Manage. 2006; 32(3): 287-293.

Wasan AD, Butler SF, Budman SH, et al.: Does report of craving opioid medication predict aberrant drug behavior among chronic pain patients? Clin J Pain. 2009; 25(3): 193-198.

Wasan AD, Ross EL, Michna E, et al.: Craving of prescription opioids in patients with chronic pain: A longitudinal outcomes trial. J Pain. 2012; 13(2): 146-154.

Turk DC, Swanson KS, Gatchel RJ: Predicting opioid misuse by chronic pain patients: A systematic review and literature synthesis. Clin J Pain. 2008; 24(6): 497-508.

Paulozzi LJ, Weisler RH, Patkar AA: A national epidemic of unintentional prescription opioid overdose deaths: How physicians can help control it. J Clin Psychiatry. 2011; 72(5): 589-592.

Dunn KM, Saunders KW, Rutter CM, et al.: Opioid prescriptions for chronic pain and overdose: A cohort study. Ann Intern Med. 2010; 152(2): 85-92.

Substance Abuse and Mental Health Services Administration (SAMHSA): Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013. Available at http://www.samhsa.gov/data/sites/default/files/NSDUHnationalfindingresults2012/NSDUHnationalfindingresults2012/NSDUHresults2012.pdf. Accessed November 25, 2014.

Katz N, Dart RC, Bailey E, et al.: Tampering with prescription opioids: Nature and extent of the problem, health consequences, and solutions. Am J Drug Alcohol Abuse. 2011; 37(4): 205-217.

Gourlay DL, Heit HA, Almahrezi A: Universal precautions in pain medicine: A rational approach to the treatment of chronic pain. Pain Med. 2005; 6(2): 107-112.