Prescription Opioids,
Overdose Deaths and Physician Responsibility
JAMA December 10, 2008, Volume 300, #22, 2672-2673
A. Thoms McLellan Ph.D., Barbara Turner, M.D., Ms Ed.

This editorial reported that the study of overdose deaths in West Virginia by Hall and colleagues in this issue of Jama revealed that opioid analgesics contributed to 93% of those deaths and most of these potentially avoidable deaths occurred in younger persons age 18 to 44.  These disturbing findings are certain to raise questions about physician prescribing practices, the safety and adverse affect profiles of opioid medications, and the appropriate management of pain.  These findings also raise several important questions versus physicians who are trying to balance their duty to relieve pain in individual patients and their obligation to prevent the broader public health problem of addition and overdose death. 

They proceeded to state that the 2006 death rate from unintentional overdose by prescribing drugs in West Virginia was 16.2 per 100,000 population, more than two times higher than the US average of 5.6 per 100,000 population during the same period.  Also, from 2000 to 2005, the number of opioid prescriptions in West Virginia increased at a higher rate than in most other states, although the rates of opioid prescribed increased significantly in all states. The examples from Hall et al, illustrates a significant regional variation in opioid prescribing practices and one of the direct relationships reported between rates of opioid prescribing and opioid problems such as illicit use of and overdose deaths from these opioids.  The authors stated that this data combined with the findings of Hall et al, make attempting to suggest that the time has come to restrict opioid prescriptions for chronic nonmalignant pain.  However, given the aging and the general population, the condominant increase in prevalence of pain related disease such as arthritis have demonstrated effectiveness of opioids in relieving pain, clinicians need to develop more reasonable, patient centered approaches to address chronic pain.  Rather than avoiding opioids altogether, a more reasonable response could be to limit and monitor prescriptions of opioids that are most likely to be diverted.  Another reasonable action includes structured monitoring of patients who require long-term treatment of opioids with urine drug screens and opioid agreement’s.  At present, primary care physicians appear to be only rarely using these mechanisms.  They noted that the study by Hall, that 79% of the cases of overdose deaths also tested positive for alcohol and other drugs suggesting that many to most of these individuals were addicted.  They found that 56% of decedents had no registered prescription for an opioid and another 20% had misrepresented themselves to five or more physicians to receive opioid prescription (doctor shopping).  These findings suggest that a few of the overdoses resulted from physician initiated inadvertent addiction (iatrogenic addiction). 

They cited a report of prevalence rates of iatrogenic addiction varying from 2.8% to 21% of patients prescribes long-term opioids for nonmalignant pain.  They state that part of the reason for the variability of prevalent treatments is the unfortunate confusion in terms of dependence and addiction.  They stated that most patients receiving long-term prescriptions for opioid drugs show some symptoms of physiologic dependance such as tolerance and mild to moderate withdrawal.  In contrast, addiction is a pathological behavioral syndrome characterized in part by cravings for, loss of control over, and inability to abstain from opioids.  These terms are not synonymous when physicians understand the difference.  Contributing to the confusion is the fact that some of the behavioral symptoms associated with loss of control in addiction such as demands for early refills, request for larger doses, and emotional outbursts which also results from under-medication in pain patients.  The authors were concerned re: this study which demonstrated that 56% of those whose overdose was attributed in part to prescribed opioids were never actually prescribed these medications.  Some of these opioids may have been stolen from pharmacies or from patients legitimately prescribed the opioids.  An additional source of prescribed opioids is the Internet which a wide variety of opioid analgesics can be directly purchased without a prescription. Physicians cannot control all of these types of diversions but they can advise all patients prescribed opioids to secure them in a safe place.  The authors conclude that opioid drugs have well-known analgesic benefits that also can cause serious adverse public health affects.  The clinical management of pain with opioid analgesics requires close oversight and deserves more research, especially in the context of primary care of other non-pain specialty settings. 

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The Use of Opioids in the Treatment of Back Pain
ODG (Official Disability Guidelines) Treatment in Workers Comp 2008,
Sixth Edition, copyright 2007 by Work Loss Data Institute, page 906,
in chapter entitled Low Back. 

The guidelines state that these are not generally recommended except for short use for severe cases, and not to exceed two weeks.  They state when used only for a time limited course, opioid analgesics are an option in the management of patients with acute low back problems.  The decision to use opioids should be guided by consideration of their potential complications relative to other options.  Patients should be warned about potential physical dependence and the danger associated with the use of opioids while operating heavy equipment or driving.  They refer to studies that have found that patients taking opioid analgesics did not return to full activity sooner than patients taking NSAIDS or acetaminophen.  In addition, they note that studies found no difference in pain relief between NSAIDS and opioids.  Finally, side effects of opioid analgesics were found to substantial, including the risk for physical dependence.  These side effects are an important concern in conditions that become chronic such as low back problems. 

Per the Occupational Medicine Practice Guidelines, published by the American College of Occupational and Environmental Medicine, 2008 Revision, (ACOEM Guidelines) we note per page 227, the ACOEM Guidelines state that patients should be screened prior to initiation of opioids for chronic pain.  They need to be asked about prior substance abuse, as it is important for the healthcare provider to have knowledge of prior history of drug or alcohol abuse or psychological problems that would place the patient at increased risk of developing opioid related use/abuse problems.  They recommend a psychological evaluation in most cases. 

The ACOEM Guidelines advise that the routine use of opioids for treatment of chronic nonmalignant pain conditions is not recommended although selected patients may benefit from judicious use.  They state that these patients need to be carefully selected and evaluated and monitored closely.  They note that factors that could place the patient at particular risk would be a history of depression, substance dependance, personality disorder.  They recommend that all patients on chronic opioids for chronic pain should undergo routine use of urine drug screening as there is evidence that urine drug screens can identify aberrant opioid use and other substance use that otherwise is not apparent to the treating physicians.  They state that screening is recommended at baseline, randomly at least twice and up to four times a year and the termination of this medication regimen.  Screening should also be performed if there is suspicion of substance abuse including oversedating drugs, intoxication, motor vehicle crash or other accidents or injuries, driving while intoxicated, premature prescription renewals, self directed dose changes, lost or stolen prescriptions, using more than one provider per prescriptions, non-pain use of medication, using alcohol for pain treatment or excessive alcohol use, missed appointments, hoarding of medications and selling medications.  They recommend standard urine drug/toxicology screening in addition to consultation with a qualified medical officer when needed. 

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The Risk Benefit Ratio for Opioids:
An Increasingly Uncomfortable Relationship
The Back Letter volume 24 #1 January 2009

The risk benefit ratio for opioids in the long-term treatment of chronic musculoskeletal pain has come to an uncomfortable juncture:  There is increasingly abundant evidence of the risks of opioid therapy while the benefits remain uncertain.  The United States is approximately 10 years into a massive experiment in the widespread use of opioids for chronic muscular pain, one that occurred without an adequate evidence base.  New studies demonstrate that medicine’s premature leap into widespread opioid use has triggered a disturbing wave of drug diversions, drug abuse and drug overdoses.  They quoted Von Korff and Deyo stating observational studies are making it clear that pain control is often not very effective.  They quoted Turk who had reported that on the average, opioid medications reduce pain by only 30 to 35% and usually in less than 40% of patients.   Turk stated that there was a pressing need for scientific research that might help select individuals with chronic pain for opioid therapy.  The authors pointed out that the number of deaths involving prescription opioid analgesic increased from 2900 in 1999 to at least 7500 in 2004, an increase of 160% in just five years.  They stated by 2004, opioid pain killer deaths numbered more than a total of deaths involving heroin and cocaine in this category.  They quoted a study by Licciardone, 2008, noting that ambulatory care for back pain in the United States estimated that about 28% of patients with chronic low back pain received a prescription for opioids in 2003, 2004.  They cited that the growing popularity of this treatment clearly raises the ante in terms of public safety.