Nonfatal Opioid Overdose No Bar to Further Prescriptions

Megan Brooks

December 29, 2015

The overwhelming majority of people who survive an overdose of prescription opioids continue to be prescribed opioids afterward, often by the same prescriber, according to a new study.

"We found the degree of continued prescribing both surprising and concerning," lead investigator Marc Larochelle, MD, MPH, from Boston Medical Center, in Massachusetts, told Medscape Medical News.

Using the Optum national commercial insurance claims database, the researchers identified 2848 individuals aged 18 to 64 years who suffered a nonfatal opioid overdose while taking opioids for chronic noncancer pain. Digging deeper, they discovered that 91% of these patients (n = 2597) received one or more opioid prescriptions in the follow-up period after the overdose (median, 299 days).

Dr Marc Larochelle

This is an "astonishing" finding, writes Jessica Gregg, MD, PhD, of Central City Concern, Portland, Oregon, in an editorial published with the study December 28 in Annals of Internal Medicine.

The researchers also found that 212 patients (7%) suffered a repeat opioid overdose. At 2 years, the cumulative incidence of repeat overdose was 17% for patients receiving high doses of opioids (≥100 morphine-equivalent dosage) after the index overdose, 15% for those receiving moderate doses, 9% for those receiving low doses, and 8% for those receiving no opioids.

"Continued prescribing at high dosages was associated with a doubling of the risk of repeated overdose over 2 years of follow-up compared with discontinuing prescription opioids," Dr Larochelle told Medscape Medical News.

The study also found that 70% of patients who continued to receive opioids after the overdose obtained them from a prescriber who had treated them before the overdose. However, after an overdose, the prescribed opioid dosages decreased to levels that were substantially lower than dosages received in the 3 months before the event, and dosages stabilized at those lower levels, the researchers report.

Opportunity for Change

"We need to do a better job as a health system in identifying and intervening when patients prescribed opioids for chronic pain begin to experience opioid-related harms," Dr Larochelle told Medscape Medical News.

In her editorial, Dr Gregg notes that prescribing guidelines state clearly that adverse events, such as overdose, are "compelling reasons to withdraw prescription opioids. Therefore, it is tempting, and it would be easy, to attribute these results to poor care, bad decisions, or sloppy prescribing. However, the problem goes well beyond individual prescribers' practices. These prescribing behaviors occur in a context in which substantial ― even deadly ― mistakes are inevitable."

For instance, it is likely that many of the prescribers in the study did not know about their patients' overdoses, Dr Gregg notes, given that currently there are no widespread systems in place for notifying providers when overdoses occur. "Until such systems exist, providers will be left to act with dangerously limited knowledge. They will be unlikely to decrease or withdraw a patient's opioid prescription after an overdose if they have no knowledge that the event occurred," she writes.

Prescribers need to know when their patients overdose, and they need sufficient knowledge and support to act on that information, Dr Gregg says. They need to know how to taper opioid dosages appropriately, how to use and prescribe buprenorphine (multiple brands), and what resources they can call on to help patients who insist on receiving opioids that their providers believe will do more harm than good.

This will require substantial changes in both medical education and current systems of care, Dr Gregg acknowledges. "These changes include more comprehensive education for medical students and residents about pain, addiction, and treatments for both. They also include building on models for chronic disease management and patient-centered care and on local and regional initiatives that recognize pain and addiction as chronic diseases that require team approaches for optimal outcomes," she writes.

Healthcare systems also need to provide physicians with the tools, time, and resources to identify and help patients with or at risk for opioid use disorders, Dr Gregg notes.

"These are not quick fixes, and they will be difficult. However, if we do not act now to fix these systems of care, patients will continue to suffer — and even die — and physicians will continue believe that they are powerless to stop it," she concludes.

More people died from drug overdoses in the United States in 2014 than during any previous year on record, with increases in opioid overdose deaths being the driving factor, according to statistics released earlier this month by the US Centers for Disease Control and Prevention.

The study was supported by the Health Resources and Services Administration. Dr Larochelle received grants from the Health Resources and Services Administration and the Ryoichi Sasakawa Fellowship Fund and nonfinancial support from the Harvard Pilgrim Health Care Institute during the conduct of the study. Dr Gregg has disclosed no relevant financial relationships.

Ann Intern Med. Published online December 29, 2015. Abstract, Editorial

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