Reflections Regarding Opioid Prescribing After Nonfatal Overdose

This post is authored by CT Chapter Council Member Daniel G. Tobin, MD, FACP, Assistant Professor of Medicine, Yale University School of Medicine

Clinicians frequently prescribe opioids for chronic non-cancer pain despite their questionable therapeutic efficacy and having little or no formal training in pain management.1-3  Not surprisingly, this has contributed to an epidemic of unintentional overdose deaths.  Highlighting this crisis, in 2009 the risk of dying from an unintentional overdose exceeded the mortality risk of motor vehicle accidents, making it the leading cause of accidental death in the United States.4  Now, a recent study further elevates the level of concern.

In a startling retrospective cohort study by Larochelle and colleagues5, they found that more than 90% of chronic pain patients who present to the emergency room or hospital with a non-fatal opioid overdose continue to receive opioids after the event, typically prescribed by the same provider, and 7% had a subsequent overdose event during the study period.  This data undoubtedly underestimates the true frequency of this phenomenon since the authors excluded patients who suffered an overdose death or did not present to a health care facility.  Additionally, the mean daily opioid dosage in the 60 days prior to overdose was quite high (ranging from a morphine-equivalent dose of 152-164 mg), and increased rapidly in the week prior to the event.  As alarming as these findings are, they suggest a number of opportunities for intervention.

First, the authors rightly point out that in many cases the prescriber may have been unaware that the opioid overdose happened, as evidenced by the fact that 70% of the patients continued to receive opioids from the same prescriber as before the event.  In most states (including Connecticut), there is currently no standardized mechanism to report such an event back to the prescriber through their central Prescription Monitoring and Reporting System.  Similarly, providers do not routinely receive event notification from insurance carriers despite the availability of claim data that could identify such episodes.  Furthermore, direct contact between the hospital and the outpatient prescriber is sporadic and the information does not automatically follow the patient who chooses to go elsewhere for their future care.  Addressing these shortcomings is a critical step toward improving safety.

Additionally, these data again correlate higher prescribed opioid doses with increased risk of overdose, as has been demonstrated previously6.  Pharma-sponsored publications have pushed back on this idea7, but most authorities recommend caution as the dose rises.  It is also notable that in this study the mean opioid dose escalated significantly in the week prior to overdose, suggesting that rapid increase in opioid use may have overcome tolerance, even in patients already receiving high doses of opioids chronically.  Dose increases should be made cautiously, even for experienced opioid users.

Although not discussed by the authors, this study also highlights the importance of access to the opioid-reversal agent naloxone (Narcan).  Treatment with naloxone was undoubtedly lifesaving in this cohort, and enhanced access and use of this drug in the outpatient setting is of profound importance.  This is particularly relevant since many overdose victims never present to the hospital setting.  Connecticut now allows via Public Act 15-198 certified pharmacists to directly dispense, without a physician’s prescription, the opioid antagonist naloxone, but prescribing and counseling patients about the risk for overdose and appropriate use of naloxone remains a core responsibility of the prescriber.  Like a fire extinguisher that one hopes to never use, having naloxone on hand is a very important preventative measure.

Opioid therapy will continue to have a role in the treatment of chronic non-cancer pain for the foreseeable future, but we should reflect on these findings and improve overdose prevention efforts whenever possible.  In addition, once it becomes clear that the risk for harm outweighs the expected benefit for an individual patient, prescribers should carefully taper and discontinue opioid therapy.  When appropriate, referral for treatment of opioid abuse and dependence should also occur.  We should always strive to treat pain, but we must first do no harm.

References:

  1. Chou R, Turner JA, Devine EB, et al. The Effectiveness and Risks of Long-Term Opioid Therapy for Chronic Pain: A Systematic Review for a National Institutes of Health Pathways to Prevention WorkshopEffectiveness and Risks of Long-Term Opioid Therapy for Chronic Pain. Ann Intern Med. 2015;162(4):276-286.
  2. Roehr B. US needs new strategy to help 116 million patients in chronic pain. BMJ. 2011;343:d4206.
  3. McCarberg BH, Nicholson BD, Todd KH, Palmer T, Penles L. The impact of pain on quality of life and the unmet needs of pain management: results from pain sufferers and physicians participating in an Internet survey. American Journal of Therapeutics. 2008;15(4):312-320.
  4. Paulozzi L, Dellinger A, Degutis L. Lessons from the past. Injury Prevention:Journal of the International Society for Child and Adolescent Injury Prevention. 2012;18(1):70.
  5. Larochelle MR, Liebschutz JM, Zhang F, Ross-Degnan D, Wharam JF. Opioid Prescribing After Nonfatal Overdose and Association With Repeated Overdose: A Cohort Study. Ann Intern Med. 2016;164(1):1-9.
  6. 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.
  7. DeVeaugh-Geiss A, Coplan P, Kadakia A, Chilcoat H. Is opioid dose a strong predictor of the risk of opioid overdose? Important confounding factors that change the dose-overdose relationship. Drug & Alcohol Dependence. 2015;146:e265.

 

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