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91% who overdose on opioids continue to receive opioid prescriptions

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‘Astonishing’ findings

It’s tempting to attribute these astonishing findings to poor medical care, bad medical decisions, or sloppy prescribing, but the problem extends well beyond individual prescribers’ practices. These prescribing behaviors take place within a context in which substantial, even deadly, mistakes are inevitable.

Clinicians must be notified when their patients overdose and must know how to act on that notification. They must be taught to recognize pain and addiction as chronic diseases that require team approaches. They must learn how to taper opioid dosages appropriately, how to use buprenorphine, and what other resources in their communities are reliable. Health systems must give physicians the tools and the time they need to identify and coordinate care for affected patients, and would do well to connect overdose patients directly to addiction services at hospital discharge.

This approach would turn an opioid overdose from a devastating event into an opportunity for hope.

Dr. Jessica Gregg is at Central City Concern, a nonprofit agency serving adults and families impacted by homelessness, poverty, and addiction in Portland, Ore. She reported having no relevant financial conflicts of interest. Dr. Gregg made these remarks in an editorial accompanying Dr. Larochelle’s report (Ann Intern Med. 2015 Dec 28. doi: 10.7326/M152687).


 

FROM ANNALS OF INTERNAL MEDICINE

References

Almost all patients who had nonfatal overdoses while taking long-term opioids for noncancer pain continued to receive opioid prescriptions, usually from the same physicians, 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 analyzed information in a database of inpatient, outpatient, and pharmacy claims from a large U.S. health insurer covering all 50 states.

They focused on 2,848 insured adults enrolled 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, meperidine, morphine, oxycodone, hydrocodone, hydromorphone, fentanyl, oxymorphone, propoxyphene, methadone, tramadol, and levorphanol, said Dr. Marc R. Larochelle of Boston Medical Center and his associates.

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A total of 2,597 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 1,198 cases (61%). Two hundred twelve of these patients (7%) had another opioid overdose 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; however, some prescribers may have been unaware 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 providers 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 misuse, 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 sufficient. … 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 opportunity to improve the safety of opioid prescribing, but that most prescribers at present are missing this opportunity.

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