Opioid-related Overdose Deaths Research Articles

Changes in Provider Prescribing Patterns After Implementation of an Emergency Department Prescription Opioid Policy

BackgroundPrescription opioid-associated abuse and overdose is a significant cause of morbidity and mortality in the United States. Opioid prescriptions generated from emergency departments (EDs) nationwide have increased dramatically over the past 20 years, and opioid-related overdose deaths have become an epidemic, according to the Centers for Disease Control and Prevention. ObjectiveOur aim was to determine the effectiveness of implementing a prescription policy for opioids on overall opioid prescribing patterns in a hospital ED. MethodsThe ED provider group of an academic, non-university–affiliated urban hospital with 23,000 annual patient visits agreed to opioid prescribing guidelines for chronic pain with the goal of limiting prescriptions that may be used for abuse or diversion. These guidelines were instituted in the ED through collaborative staff meetings and educational and training sessions. We used the electronic medical record to analyze the number and type of opioid discharge prescriptions during the study period from 2006–2014, before and after the prescribing guidelines were instituted in the ED. ResultsThe number of patients discharged with a prescription for opioids decreased 39.6% (25.7% to 15.6%; absolute decrease 10.2%; 95% confidence interval [CI] 9.6–10.7; p < 0.001) after the intervention. The improvements were sustained 2.5 years after the intervention. Decreases were seen in all major opioids (hydrocodone, oxycodone, hydromorphone, and codeine). The number of pills per prescription also decreased 14.8%, from 19.5% to 16.6% (absolute decrease 2.9; 95% CI 2.6–3.1; p < 0.001). ConclusionsImplementation of an ED prescription opioid policy was associated with a significant reduction in total opioid prescriptions and in the number of pills per prescription.

Declines in Opioid Prescribing After a Private Insurer Policy Change - Massachusetts, 2011-2015.

Overdose deaths involving opioid pain medications are epidemic in the United States, in part because of high opioid prescribing rates and associated abuse of these drugs (1). In 2014, nearly 2 million U.S. residents either abused or were dependent on prescription opioids (2). In Massachusetts, unintentional opioid-related overdose deaths, including deaths involving heroin, increased 45% from 2012 to 2013.* In 2014, the rate of these deaths reached 20.0 per 100,000, nearly 2.5 times higher than the U.S. rate overall (3,4). On July 1, 2012, Blue Cross Blue Shield of Massachusetts (BCBSMA), the largest insurer in the state with approximately 2.8 million members,† implemented a comprehensive opioid utilization program after learning that many of its members were receiving new prescriptions with a >30-day supply of opioids. The 2016 CDC Guideline for Prescribing Opioids for Chronic Pain recommends avoiding opioids as a first-line therapy for chronic pain and limiting quantities when initiating opioids for acute pain (5). CDC analyzed BCBSMA prescription claims data for the period 2011-2015 to assess the effect of the new utilization program on opioid prescribing rates. During the first 3 years after policy implementation, the average monthly prescribing rate for opioids decreased almost 15%, from 34 per 1,000 members to 29. The percentage of BCBSMA members per month with current opioid prescriptions also declined. The temporal association between implementation of the program and statistically significant declines in both prescribing rates and proportion of members using opioids suggests that the BCBSMA initiative played a role in reducing the use of prescription opioids among its members. Public and private insurers in the United States could benefit from developing their own best practices for prescription opioid utilization that ensure accessible pain care, while reducing the risk for dependence and abuse associated with these drugs.

Implementation Of Prescription Drug Monitoring Programs Associated With Reductions In Opioid-Related Death Rates.

Over the past two decades the number of opioid pain relievers sold in the United States rose dramatically. This rise in sales was accompanied by an increase in opioid-related overdose deaths. In response, forty-nine states (all but Missouri) created prescription drug monitoring programs to detect high-risk prescribing and patient behaviors. Our objectives were to determine whether the implementation or particular characteristics of the programs were effective in reducing opioid-related overdose deaths. In adjusted analyses we found that a state's implementation of a program was associated with an average reduction of 1.12 opioid-related overdose deaths per 100,000 population in the year after implementation. Additionally, states whose programs had robust characteristics-including monitoring greater numbers of drugs with abuse potential and updating their data at least weekly-had greater reductions in deaths, compared to states whose programs did not have these characteristics. We estimate that if Missouri adopted a prescription drug monitoring program and other states enhanced their programs with robust features, there would be more than 600 fewer overdose deaths nationwide in 2016, preventing approximately two deaths each day.

Could chest wall rigidity be a factor in rapid death from illicit fentanyl abuse?

Background: There has been a significant spike in fentanyl-related deaths from illicit fentanyl supplied via the heroin trade. Past fentanyl access was primarily oral or dermal via prescription fentanyl patch diversion. One factor potentially driving this increase in fatalities is the change in route of administration. Rapid intravenous (IV) fentanyl can produce chest wall rigidity. We evaluated post-mortem fentanyl and norfentanyl concentrations in a recent surge of lethal fentanyl intoxications. Methods: Fentanyl related deaths from the Franklin County coroner’s office from January to September 2015 were identified. Presumptive positive fentanyl results were confirmed by quantitative analysis using liquid chromatography tandem mass spectrometry (LC/MS/MS) and were able to quantify fentanyl, norfentanyl, alfentanyl, and sufentanyl. Results: 48 fentanyl deaths were identified. Mean fentanyl concentrations were 12.5 ng/ml, (range 0.5 ng/ml to >40 ng/ml). Mean norfentanyl concentrations were 1.9 ng/ml (range none detected to 8.3 ng/ml). No appreciable concentrations of norfentanyl could be detected in 20 of 48 cases (42%) and were less than 1 ng/ml in 25 cases (52%). Elevated fentanyl concentrations did not correlate with rises in norfentanyl levels. In several cases fentanyl concentrations were strikingly high (22 ng/ml and 20 ng/ml) with no norfentanyl detected. Discussion: The lack of any measurable norfentanyl in half of our cases suggests a very rapid death, consistent with acute chest rigidity. An alternate explanation could be a dose-related rapid onset of respiratory arrest. Deaths occurred with low levels of fentanyl in the therapeutic range (1–2 ng/ml) in apparent non-naïve opiate abusers. Acute chest wall rigidity is a well-recognized complication in the medical community but unknown within the drug abuse community. The average abuser of illicit opioids may be unaware of the increasing fentanyl content of their illicit opioid purchase. Conclusion: In summary we believe sudden onset chest wall rigidity may be a significant and previously unreported factor leading to an increased mortality, from illicit IV fentanyl use. Fentanyl and norfentanyl ratios and concentrations suggest a more rapid onset of death given the finding of fentanyl without norfentanyl in many of the fatalities. Chest wall rigidity may help explain the cause of death in these instances, in contrast to the typical opioid-related overdose deaths. Intravenous heroin users should be educated regarding this potentially fatal complication given the increasingly common substitution and combination with heroin of fentanyl.

A Reality Check: The Need for a Deeper Understanding of Opioid Abuse Treatment Options: A Policy Statement From the American College of Clinical Pharmacology.

Most clinical pharmacologists agree that prescription drug abuse is no longer just a trending topic; it has reached epidemic levels in the United States. Although the United States makes up less than 5% of the global population, 80% of the opioids and 99% of the hydrocodone used in the world are used by people in the United States.1 Members of the American College of Clinical Pharmacology (ACCP) are intimately involved with the development of novel drugs, many for the treatment of chronic pain. The ACCP is uniquely positioned to serve both its membership and the public by providing scientific knowledge to optimize research, development, and the utilization of medication for the benefit of all, which is the vision of the organization. This position paper asserts that increased physician, pharmacist, and scientific researcher education is the best way to create a better understanding of opioid abuse and dependence as well as its treatment. Understanding, acceptance, and the promotion of supervised treatment options such as combined psychotherapy with Suboxone treatment paradigms provide rapid and significant lifesaving options as compared to programs relying on complete abstinence. Additionally, the FDA's recent guidances2, 3 supporting the development of abuse deterrent formulations of opioids and the thorough evaluation of the potential of a new chemical entity (NCE) to be abused has been proposed to prevent the widespread tampering that currently occurs through both patient abuse and general diversion of the supply.

Naloxone distribution to drug users in California and opioid-related overdose death rates

Aims:Opioid-related overdose is a leading cause of death in the United States. Since the 1990s, one response to increased overdose has been the distribution of naloxone, an opioid antagonist, to drug users and those in their immediate social circles. By 2010, at least 188 organizations were distributing naloxone to drug users in the United States, and collectively reported training at least 53,000 lay individuals to use naloxone, leading to at least 10,000 successful overdose reversals. In California, programs distributing naloxone exist in 14 of the state’s 58 counties, allowing exploration of the impact of such programs on rates of over-dose death. Methods: To assess the impact of naloxone programs on accidental overdose deaths in California over an 11 year period, we fit four Poisson generalized linear mixed models, employing four different offset terms: all accidental poison deaths; all accidental deaths; all deaths; and population per county per year. Results: The overall effect of naloxone distribution was statistically significant for accidental overdose deaths as a proportion of all deaths (p=0008),with a significant effect for intervention×year (p=0002), indicating that naloxone programs are associated with reductions in the rate at which overdose deaths grow as a proportion of all deaths. The overall effect of the intervention was also statistically significant for accidental overdose deaths as a proportion of county population (p<0001), with a significant effect for intervention x year (p<0001), indicating that naloxone programs are associatedwith reductions in the rate atwhich overdose deaths grow as a proportion of county population. Conclusions: Our analysis provides support for the argument that distributing naloxone to active drug users and those around them reduces deaths. Financial support: NIH/NIDA 5K01DA032443 CTRI Catalyst grant 8184, funded by NIH/NCATS UL1TR000100 NIH/NIDA K01DA031031.

Prescription Opioid Misuse, Abuse, Morbidity, and Mortality: Balancing Effective Pain Management and Safety

The burgeoning rate of prescription opioid misuse, abuse, addiction, and opioid related overdose deaths has gained substantial professional and national media attention. This manuscript provides a narrative review and critique of the literature on prescription opioid misuse, abuse, addiction and opioid-related mortality and discusses future research needs in this area. Current literature on misuse, abuse, addiction and opioid related fatalities was reviewed in patients with chronic noncancer pain receiving long-term prescription opioid therapy. There have been inconclusive results on the efficacy of long-term opioid therapy in patients with chronic pain but moderate level evidence of dose-dependent risk of harm. The estimated prevalence of prescription opioid abuse and opioid use disorders ranges from <1% to 40% due to the paucity of uniform definitions of what constitutes misuse, abuse, and addiction but several recent studies have developed unique methodology to more accurately assess these states in the pain population. The rate of opioid-related overdose deaths is not inconsequential and a number of patient related and medication specific risk factors have been identified that may provide a basis for risk mitigation strategies. Accurately assessing the prevalence of misuse, abuse, and addiction in the pain population has been challenging due to inconsistent definitions between studies. Additional high-quality research is needed in this area utilizing consistent definitions and in reducing the risk of opioid-related overdose fatalities.

(179) Predicting opioid prescribing: influence of an expert opioid-risk evaluation

The misuse/abuse of opioids has increased across the U.S., causing a significant rise in opioid-related overdose deaths. Physicians report having difficulty discerning substance abuse/drug diversion, and research suggests patient characteristics (sex, race, age) may unduly influence providers’ pain management decisions. With the rise in interdisciplinary care, it may be possible to ease physicians’ prescribing decisions and reduce prescribing bias through the assistance of mental health professionals.

Torsades De Pointes Induced by Methadone and Clonazepam Use

Background: While recent data showed that illicit drug use rates at six months of treatment with either methadone or buprenorphine were comparable among patients [1] and that slow-release oral morphine was not inferior to methadone as detoxification treatment [2], methadone continues to be commonly prescribed in drug addiction centers [3]. The compound was developed in Germany in 1937, by scientists who sought to solve Germany's longstanding opioid shortage and derive a synthetic opium from readily available precursors [4]. According to the most recent CDC statistics, between the period of 1999 to 2006, the number of deaths from opioid pain relievers more than tripled in the U.S., from 4,000 to 13,800. Of these, deaths from methadone overdose increased from 790 to 5,420 individuals. Methadone was involved in approximately one in three opioid-related overdose deaths [5]. This medication has been implicated in prolongation of the QT interval which may predispose to Torsades de Pointes, a fatal cardiac arrhythmia. The mechanism of QT prolongation by methadone, is thought to be the result of inhibition of the hERG K+ channel [6].

Prescription opioid abuse: a literature review of the clinical and economic burden in the United States.

Between 2002 and 2007, the nonmedical use of prescription pain relievers grew from 11.0 million to 12.5 million people in the United States. Societal costs attributable to prescription opioid abuse were estimated at $55.7 billion in 2007. The purpose of this study was to comprehensively review the recent clinical and economic evaluations of prescription opioid abuse. A comprehensive literature search was conducted for studies published from 2002 to 2012. Articles were included if they were original research studies in English that reported the clinical and economic burden associated with prescription opioid abuse. A total of 23 studies (183 unique citations identified, 54 articles subjected to full text review) were included in this review and analysis. Findings from the review demonstrated that rates of opioid overdose-related deaths ranged from 5528 deaths in 2002 to 14,800 in 2008. Furthermore, overdose reportedly results in 830,652 years of potential life lost before age 65. Opioid abusers were generally more likely to utilize medical services, such as emergency department, physician outpatient visits, and inpatient hospital stays, relative to non-abusers. When compared to a matched control group (non-abusers), mean annual excess health care costs for opioid abusers with private insurance ranged from $14,054 to $20,546. Similarly, the mean annual excess health care costs for opioid abusers with Medicaid ranged from $5874 to $15,183. The issue of opioid abuse has significant clinical and economic consequences for patients, health care providers, commercial and government payers, and society as a whole.

Non-medical use of non-opioid psychotherapeutic medications in a community-based cohort of HIV-infected indigent adults

BackgroundNon-opioid psychotherapeutic medications significantly increase the risk of opioid overdose-related deaths. We prospectively followed HIV-infected indigent adults sampled from the community to examine rates of and factors associated with non-medical use of benzodiazepines, muscle relaxants, and prescription stimulants. MethodsWe interviewed participants quarterly for 2 years about alcohol and illicit substance use; depression; use of prescribed opioid analgesics, benzodiazepines and muscle relaxants; opioid analgesic misuse; and non-medical use (i.e., use without a prescription) of benzodiazepines, muscle relaxants, and prescription stimulants. Using mixed-effects multivariate logistic regression, we determined factors associated with non-medical use of benzodiazepines, muscle relaxants, and prescription stimulants. ResultsAmong the 296 participants at enrollment, 52.0% reported taking opioid analgesics that had been prescribed, 17.9% took benzodiazepines that had been prescribed, and 8.1% took muscle relaxants that had been prescribed. Over the 2-year study interval, 53.4% reported prescription opioid misuse, 25.3% reported non-medical use of benzodiazepines, 11.5% reported non-medical use of muscle relaxants, and 6.1% reported non-medical use of prescription stimulants. In multivariable analysis, opioid analgesic misuse in the past 90 days was associated with non-medical use of benzodiazepines, muscle relaxants, and prescription stimulants during the same time interval. Illicit substance use and depression were not associated with non-medical use of these medications. ConclusionsPrescription opioid analgesic misuse is associated with non-medical use of other psychotherapeutic medications. Health care providers should monitor for non-medical use of a broad array of psychoactive medications among high-risk populations to minimize harm.

High-Risk Use by Patients Prescribed Opioids for Pain and Its Role in Overdose Deaths

From January 1, 2003, through December 31, 2010, drug overdose deaths in Tennessee increased from 422 to 1059 per year. More of these deaths involved prescription opioids than heroin and cocaine combined. To assess the contribution of certain opioid-prescribing patterns to the risk of overdose death. We performed a matched case-control study that analyzed opioid prescription data from the Tennessee Controlled Substances Monitoring Program (TNCSMP) from January 1, 2007, through December 31, 2011, to identify risk factors associated with opioid-related overdose deaths from January 1, 2009, through December 31, 2010. Case patients were ascertained from death certificate data. Age- and sex-matched controls were randomly selected from among live patients in the TNCSMP. We defined a high-risk number of prescribers or pharmacies as 4 or more per year and high-risk dosage as a daily mean of more than 100 morphine milligram equivalents (MMEs) per year. The main outcome was opioid-related overdose death. From January 1, 2007, through December 31, 2011, one-third of the population of Tennessee filled an opioid prescription each year, and opioid prescription rates increased from 108.3 to 142.5 per 100 population per year. Among all patients in Tennessee prescribed opioids during 2011, 7.6% used more than 4 prescribers, 2.5% used more than 4 pharmacies, and 2.8% had a mean daily dosage greater than 100 MMEs. Increased risk of opioid-related overdose death was associated with 4 or more prescribers (adjusted odds ratio [aOR], 6.5; 95% CI, 5.1-8.5), 4 or more pharmacies (aOR, 6.0; 95% CI, 4.4-8.3), and more than 100 MMEs (aOR, 11.2; 95% CI, 8.3-15.1). Persons with 1 or more risk factor accounted for 55% of all overdose deaths. High-risk use of prescription opioids is frequent and increasing in Tennessee and is associated with increased overdose mortality. Use of prescription drug–monitoring program data to direct risk-reduction measures to the types of patients overrepresented among overdose deaths might reduce mortality associated with opioid abuse.

Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis

Objective To evaluate the impact of state supported overdose education and nasal naloxone distribution (OEND) programs on rates of opioid related death from overdose and acute care utilization in Massachusetts.Design...

National trends in pharmaceutical opioid related overdose deaths compared to other substance related overdose deaths: 1999–2009

BackgroundPharmaceutical opioid related deaths have increased. This study aimed to place pharmaceutical opioid overdose deaths within the context of heroin, cocaine, psychostimulants, and pharmaceutical sedative hypnotics examine demographic trends, and describe common combinations of substances involved in opioid related deaths. MethodsWe reviewed deaths among 15–64 year olds in the US from 1999–2009 using death certificate data available through the CDC Wide-Ranging Online Data for Epidemiologic Research (WONDER) Database. We identified International Classification of Disease-10 codes describing accidental overdose deaths, including poisonings related to stimulants, pharmaceutical drugs, and heroin. We used crude and age adjusted death rates (deaths/100,000 person years [p-y] and 95% confidence interval [CI] and multivariable Poisson regression models, yielding incident rate ratios; IRRs), for analysis. ResultsThe age adjusted death rate related to pharmaceutical opioids increased almost 4-fold from 1999 to 2009 (1.54/100,000 p-y [95% CI 1.49–1.60] to 6.05/100,000 p-y [95% CI 5.95–6.16; p<0.001). From 1999 to 2009, pharmaceutical opioids were responsible for the highest relative increase in overdose death rates (IRR 4.22, 95% CI 3.03–5.87) followed by sedative hypnotics (IRR 3.53, 95% CI 2.11–5.90). Heroin related overdose death rates increased from 2007 to 2009 (1.05/100,000 persons [95% CI 1.00–1.09] to 1.43/100,000 persons [95% CI 1.38–1.48; p<0.001). From 2005–2009 the combination of pharmaceutical opioids and benzodiazepines was the most common cause of polysubstance overdose deaths (1.27/100,000 p-y (95% CI 1.25–1.30). ConclusionStrategies, such as wider implementation of naloxone, expanded access to treatment, and development of new interventions are needed to curb the pharmaceutical opioid overdose epidemic.

Characterization of Prescription Opioid Abuse in the United States: Focus on Route of Administration

ABSTRACTPrescription opioids are prescribed increasingly for the management of chronic pain, and this has been accompanied by a dramatic rise in opioid-related abuse, addiction, and overdose deaths. Reports of abuse involving nonoral administration (e.g., snorting, injecting) of prescription opioids are increasing, although the epidemiology of oral versus nonoral abuse is not well understood. Available data indicate that oral abuse is far more common, with 72% to 97% of opioid abusers perferring oral administration. Factors associated with nonoral administration include longer duration of opioid abuse, male gender, and rural setting. Extended-release opioids, because of their relatively high drug load, may be attractive to experienced abusers seeking to manipulate the formulation to facilitate a rapid onset of effect. Putative abuse-deterrent formulations have been developed to decrease the likelihood or consequences of nonoral abuse. In addition, Risk Evaluation and Mitigation Strategies (REMS) are now required for prescribed extended-release/long-acting opioids by the US Food and Drug Administration, although their effectiveness in reducing the risk of abuse, addiction, and overdose has not been evaluated. Physicians should remain vigilant when prescribing opioids and should exercise appropriate patient selection, perform risk analysis and stratification, and maintain continuous patient monitoring to ensure the benefits outweigh these important risks.

Unintentional prescription opioid-related overdose deaths: description of decedents by next of kin or best contact, Utah, 2008-2009.

Little is known about the characteristics that may predispose an individual to being at risk for fatal overdose from prescription opioids. To identify characteristics related to unintentional prescription opioid overdose deaths in Utah. Interviews were conducted (October 2008-October 2009) with a relative or friend most knowledgeable about the decedent's life. Analyses involved 254 decedents aged 18 or older, where cause of death included overdose on at least one prescription opioid. Decedents were more likely to be middle-aged, Caucasian, non-Hispanic/Latino, less educated, not married, or reside in rural areas than the general adult population in Utah. In the year prior to death, 87.4 % were prescribed prescription pain medication. Reported potential misuse prescription pain medication in the year prior to their death was high (e.g., taken more often than prescribed [52.9 %], obtained from more than one doctor during the previous year [31.6 %], and used for reasons other than treating pain [29.8 %, almost half of which "to get high"]). Compared with the general population, decedents were more likely to experience financial problems, unemployment, physical disability, mental illness (primarily depression), and to smoke cigarettes, drink alcohol, and use illicit drugs. The primary source of prescription pain medication was from a healthcare provider (91.8 %), but other sources (not mutually exclusive) included: for free from a friend or relative (24 %); from someone without their knowledge (18.2 %); purchase from a friend, relative, or acquaintance (16.4 %); and purchase from a dealer (not a pharmacy) (11.6 %). The large majority of decedents were prescribed opioids for management of chronic pain and many exhibited behaviors indicative of prescribed medication misuse. Financial problems, unemployment, physical disability, depression, and substance use (including illegal drugs) were also common.

Pharmacokinetics of Intranasal Crushed OxyContin and Intravenous Oxycodone in Nondependent Prescription Opioid Abusers

Prescription opioid misuse and unintentional overdose deaths involving these analgesics are increasing public health concerns among all ages in the United States.1-4 According to the US Centers for Disease Control and Prevention, prescription opioid-related overdose deaths have become the leading cause of injury deaths, outpacing motor-vehicle crashes in 6 US states and Washington, DC, in 2006.5 The increases in illicit prescription opioid use and related deaths are associated with a marked increase in number of opioid prescriptions written.6,7 OxyContin (Purdue Pharma) is an extended-release oxycodone formulation approved by the US Food and Drug Administration (FDA) for treatment of moderate to severe pain. It is a Schedule II controlled substance in the United States with a significant history of aggressive commercial marketing as well as abuse and diversion.8,9 Pharmacokinetic studies of orally administered OxyContin report a mean terminal half-life (t1/2) of approximately 4.5 to 6.5 hours, mean time to maximum concentration (Tmax) of 2.5 to 5 hours, and oral bioavailability equivalent to immediate-release oxycodone (mean 60%, standard deviation [SD] 20%).10-12 Oxycodone is metabolized by N-demethylation via cytochrome P450 3A4 to noroxycodone, its primary metabolite. It is unlikely that noroxycodone contributes to the pharmacodynamic response in humans, because it has 4-fold lower affinity for the receptor than oxycodone and low μ-opioid receptor activation in GTPγS binding studies.13 However, oxycodone also is metabolized by O-demethylation via cytochrome P450 2D6 to oxymorphone,13 a μ-opioid agonist with analgesic potency approximately 10 times that of parenteral morphine.14 Immediate-release oxycodone products are prescribed approximately 5 times more frequently than extended-release oxycodone products; however, emergency department visits report the nonmedical use of extended-release oxycodone products approximately 4 times more often than immediate-release oxycodone products.15 OxyContin tablets can be easily crushed and snorted or injected to bypass the sustained-release feature, which likely contributes to its abuse liability. In 2008, 15% of publically funded substance abuse treatment admissions with prescription opioid abuse (eg, abuse defined as substance causing problems leading to the admission) reported snorting prescription opioids.16 However, there are no intranasal (IN) pharmacokinetic data demonstrating that OxyContin tablets have immediate-release characteristics when crushed, and the IN bioavailability of OxyContin is unknown despite its common misuse by this route. Thus, this study evaluated the pharmacokinetics of oxycodone and its key metabolites when administered as IN crushed OxyContin tablets compared with intravenous (IV) immediate-release oxycodone solution.

Opioid Overdose-Related Deaths—Reply

Opioid Overdose-Related Deaths—Reply

PC-FACS

PC-FACS (Fast Article Critical Summaries for Clinicians in Palliative Care), an electronic publication of the American Academy of Hospice and Palliative Medicine, provides palliative care clinicians with concise summaries of the most important findings from more than 50 medical and scientific journals. Each month, structured summaries and insightful commentaries on 6-10 articles help palliative care clinicians stay on top of the research that is critical to contemporary practice. PC-FACS is free to AAHPM members and members can earn up to 3 CME credits quarterly. Following are excerpts from recent issues, and comments from readers are welcomed at resources@aahpm.org.

An Analysis of the Root Causes for Opioid-Related Overdose Deaths in the United States

A panel of experts in pain medicine and public policy convened to examine root causes and risk factors for opioid-related poisoning deaths and to propose recommendations to reduce death rates. Panelists reviewed results from a search of PubMed and state and federal government sources to assess frequency, demographics, and risk factors for opioid-related overdose deaths over the past decade. They also reviewed results from a Utah Department of Health study and a summary of malpractice lawsuits involving opioid-related deaths. National data demonstrate a pattern of increasing opioid-related overdose deaths beginning in the early 2000s. A high proportion of methadone-related deaths was noted. Although methadone represented less than 5% of opioid prescriptions dispensed, one third of opioid-related deaths nationwide implicated methadone. Root causes identified by the panel were physician error due to knowledge deficits, patient non-adherence to the prescribed medication regimen, unanticipated medical and mental health comorbidities, including substance use disorders, and payer policies that mandate methadone as first-line therapy. Other likely contributors to all opioid-related deaths were the presence of additional central nervous system-depressant drugs (e.g., alcohol, benzodiazepines, and antidepressants) and sleep-disordered breathing. Causes of opioid-related deaths are multifactorial, so solutions must address prescriber behaviors, patient contributory factors, nonmedical use patterns, and systemic failures. Clinical strategies to reduce opioid-related mortality should be empirically tested, should not reduce access to needed therapies, should address risk from methadone as well as other opioids, and should be incorporated into any risk evaluation and mitigation strategies enacted by regulators.