91% who overdose on opioids continue to
receive opioid prescriptions
BY MARY ANN MOON
Frontline Medical News
From Annals of Internal Medicine
A
lmost all patients who had nonfatal over-
doses while taking long-term opioids for
noncancer pain continued to receive opi-
oid prescriptions, usually from the same physi-
cians, in a nationwide cohort study published
online Dec. 28 in
Annals of Internal Medicine.
Clinical guidelines specify that adverse
events related to the misuse of opioids are
clear indications to discontinue long-term
opioid therapy. But patterns of prescribing
after opioid overdoses are not monitored. To
examine prescribing trends following nonfatal
opioid overdoses, researchers analysed infor-
mation in a database of inpatient, outpatient,
and pharmacy claims from a large US health
insurer covering all 50 states.
They focused on 2848 insured adults en-
rolled in 2000–2012 who received hospital
or ED treatment for a prescription opioid
overdose and were followed in the database
for a median of 15 months. The prescribed
drugs included codeine, dihydrocodeine, me-
peridine, morphine, oxycodone, hydrocodone,
hydromorphone, fentanyl, oxymorphone,
propoxyphene, methadone, tramadol, and
levorphanol, said Dr Marc R. Larochelle of
Boston Medical Centre and his associates.
A total of 2597 of these patients (91%)
continued to receive opioid prescriptions after
their overdose. The primary prescriber was the
same person before and after the overdose
in 1198 cases (61%). Two hundred twelve of
these patients (7%) had another opioid over-
dose during follow-up. The likelihood of a
second overdose was much higher for patients
taking the highest doses of opioids (100 mg
or more morphine-equivalent dosage per day),
with hazard ratios of 1.13 for patients taking
low doses of opioids, 1.89 for those taking
mid-range doses, and 2.57 for those taking
high doses.
“We could not determine the reason for the
treatment patterns after the overdose; how-
ever, some prescribers may have been una-
ware that the opioid overdose had occurred”
because there are no procedures in place to
ensure provider notification in such cases.
Newly introduced prescription monitoring
programs may facilitate such communication,
but a more rigorous approach would mandate
that all overdoses be reported to public health
departments, which would then notify pro-
viders and pharmacies, and perhaps secure
patient referral to substance abuse treatment
programs, the investigators said (
Ann Intern
Med
2015 Dec 28. doi: 10.7326/M15-0038).
It is possible that some overdoses stemmed
from therapeutic error rather than opioid mis-
use, and that providers felt the risk-benefit
ratio justified continued opioid treatment. But
it also is likely that many providers simply did
not have the knowledge and skills to identify
and treat opioid misuse, they added.
“Simply eliminating opioid prescribing for
patients who had an overdose is not suffi-
cient. … because some [patients] may turn
to diverted or illicit opioids. Rather, efforts to
identify and treat substance use disorders in
these patients are needed,” Dr Larochelle and
his associates said.
Overall, the study findings indicate that
nonfatal overdoses provide a meaningful op-
portunity to improve the safety of opioid pre-
scribing, but that most prescribers at present
are missing this opportunity.
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