Opioid Doses and Increased Risk for Overdose

Abstract

TO THE EDITOR: Dunn and colleagues (1) present sobering data on opioid overdose, showing a direct correlation between daily morphine equivalents and overdose rates. As echoed in the accompanying editorial by McLellan and Turner (2), these data remind every clinician prescribing opioids to thoroughly review the indication, effectiveness, and safety with patients. One safe medication-taking practice that is often overlooked is asking patients receiving long-term opioid treatment to contact the office when they are feeling unwell. Providers and patients, especially elderly patients and those with multiple comorbid conditions, should understand that the effective opioid dose when feeling relatively well may be harmful when feeling ill. Volume depletion can increase plasma concentrations of opioids (3), decreased glomerular filtration rate can promote accumulation of active opioid metabolites (4), and any co-occurring alteration in sensorium due to a variety of medical illnesses can be dramatically exacerbated by a patient’s typical opioid dose. Most worrisome is that patients who feel unwell may attempt to treat symptoms by increasing their doses of opioids or other psychoactive medications. Although adding another box to the checklist of safety reminders might make opioid prescribing even more onerous to clinicians, we strongly believe that common-sense safety measures must be part of every prescriber’s protocol to minimize adverse outcomes.