According to a study published in the April 6 issue of the Journal of the American Medical Association JAMA, receiving higher prescribed doses of opioid prescriptions is associated with an increased risk of opioid overdose death, but receiving both as-needed and regularly scheduled doses is not associated with overdose risk.
This comes as the rate of overdose death has increased sharply in the United States in the past decade and overdose death is a pressing public health problem, according to background information in the article. The study report reads, “Between 1999 and 2007, the rate of unintentional overdose death in the United States increased by 124 percent, largely because of increases in prescription opioid overdoses. Achieving a better understanding of the factors contributing to prescription opioid overdose death is an essential step toward addressing this troubling and dramatic increase in overdose mortality.”
The team of researchers led by Amy S. B. Bohnert, a psychiatrist of the Department of Veterans Affairs and the University of Michigan Medical School in Ann Arbor, examined the relationship between opioid prescribing patterns (dose and schedule [“as needed,” regularly scheduled, or both]) and risk of opioid-related deaths from 2004 through 2008 among diagnostic subgroups of patients (chronic pain, cancer, acute pain, and substance use disorders) in a national sample of Veterans Health Administration (VHA) patients. They looked at data on all unintentional prescription opioid overdose decedents (n = 750) and a random sample of patients (n = 154,684) among those individuals who used medical services in 2004 or 2005 and received opioid therapy for pain.
The results showed the rate of overdose among individuals treated with opioids to be 0.04 percent. Opioid overdose decedents were statistically significantly more likely to be middle-aged and white; more likely to have chronic or acute pain, substance use disorders, and other psychiatric diagnoses; and less likely to have cancer they noted. They also found that the overdose rate was higher at higher maximum daily doses compared with lower maximum daily doses (100 mg/day or more vs. 1 mg/day to less than 20 mg/day) across all subgroups examined, including those with cancer, substance use disorders, chronic and acute pain.
In patients with cancer having pain relieving opioids as-needed only compared with having regularly scheduled opioids was associated with an increase in risk of opioid overdose. Receiving both as-needed and regularly scheduled doses was not associated with overdose risk after adjustment. In certain cases a high dose of opioid narcotics is appropriate. For cancer patients, the National Cancer Institute (NCI) advises that when an opioid doesn't give enough pain relief, doctors may increase the dose or have the patient take the painkiller more often, or prescribe a stronger drug. “Both methods are safe and effective under your doctor's care,” the NCI says on its web site. But patients must not increase the dose of medication on their own, the NCI emphasizes.
The report reads, “The present findings highlight the importance of implementing strategies for reducing opioid overdose among patients being treated for pain…This study documents a relationship between opioid prescribing and opioid overdose in a large, national, prospective cohort of individuals receiving opioid therapy for a variety of medical conditions. The risk of opioid overdose should continue to be evaluated relative to the need to reduce pain and suffering and be considered along with other risk factors.”
“There's been some push and pull back and forth around this balance of, are we too conservative and under-treating pain as a result ... or are we using (opioids) too much and putting people at risk?” Dr. Amy Bohnert said. The number of people who both abuse opioid drugs and who overdose has been increasing in the U.S. in recent years, and about 200 million prescriptions for opioids are dispensed each year.
Bohnert said that there are likely two explanations behind the pattern she and her colleagues observed. The first, she said, is that people on higher doses of opioids have more opportunity to accidentally take too much medication in the course of their normal treatment. The other explanation is that some patients with chronic pain intentionally misuse their drugs, saving them to use recreationally, and then overdose in that context. Whether a particular patient in pain is at risk for misusing or abusing their drugs is something that should be considered whenever heavy-duty painkillers are being prescribed, Bohnert said.
Doctors, patients and their families “can work together to decide what is the right treatment for that patient,” she said. Then, they can “weigh the balance of untreated pain with the risk of overdose on a patient-by-patient basis.”
Dr. Nora Volkow, the director of the National Institute on Drug Abuse, and colleagues also reported in this week's JAMA that many patients taking opioid medications get them from multiple doctors or dentists at the same time. Addressing the problem of opioid-related overdoses is not as simple as trying to cut down on cocaine abuse, for example, Volkow said. “It is a problem that we're facing of the abuse of a substance that has very unique therapeutic purposes and can be life-saving… We cannot get rid of pain medications,” Volkow said.
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