The United States is experiencing a significant public health threat from overdose deaths involving prescription opioids for the treatment of pain. The number of fatal outcomes involving opioid analgesics more than tripled in the last decade (Figure). “The reasons for increased mortality relating to opioid prescriptions are multifactorial,” says Lynn R. Webster, MD, FACPM, FASAM. “Prescriber behaviors, patient contributory factors, non-medical use patterns, and systemic failures are among the chief culprits. These factors—as well as others—all play a role in how opioids are viewed and utilized by physicians and may contribute to fears of prescribing these medications to patients in pain.”

The FDA has instituted risk evaluation and mitigation strategies for opioids, but mortality associated with opioid prescribing continues to increase despite these efforts. Several risk factors have been identified for opioid-related overdose deaths. These include physician error due to knowledge deficits, patient non-adherence to medication regimens, and unanticipated medical and mental health comorbidities, including substance use disorders. Other risk factors include payer policies that encourage or mandate methadone as first-line therapy, the presence of additional central nervous system-depressant drugs (eg, alcohol, benzodiazepines, and antidepressants), and sleep-disordered breathing. “The analysis of risk factors is ongoing,” says Dr. Webster, “but pain care providers and public health officials must act now to prevent as many opioid-related deaths as possible.”

Causes & Risk Factors for Opioid Abuse

In the June 2011 supplement of Pain Medicine, Dr. Webster and other experts in pain management had several articles published on the root causes and risk factors pertaining to opioid-related deaths. The issue, available for free online at http://onlinelibrary.wiley.com, also discussed the extent to which measures enacted to prevent these deaths have been successful and proposed recommendations to reduce mortality rates. “These analyses are intended to help craft quality medical education programs and other interventions relating to opioid use,” says Dr. Webster. “They’re also intended to identify needed research and to inform public discussion.”

Certain demographic trends emerged from the data published in the Pain Medicine supplement. Middle age was the most vulnerable time for opioid overdose. An increase in opioid-poisoning deaths was observed in non-metropolitan centers, which translated to death rates in rural areas that are now comparable with those in urban counties. More men than women also appear to die from opioid-related causes, but women are closing the gap in vulnerability to overdose. Dr. Webster adds that approximately 50% to 60% of patients who died while taking opioids had a history of drug abuse. “Another 60% to 70% of non-medical use of opioids starts when patients seeking treatment for acute pain receive unneeded opioids, sometimes for durations that are longer than necessary.”

This is important data to have, says Dr. Webster, because it highlights the need for physicians to screen patients before prescribing opioids and to monitor them if they receive these drugs. “If patients are at risk for abusing these medications or for suicide, it’s important that physicians consider alternative treatments and medications. Not everyone will require opioids to manage their pain, and physicians must be educated on appropriate management strategies in cases when opioids are not utilized.”

A Need for Education on Opioids

Despite being one of the lowest-prescribed opioids on the market, methadone-related mortalities account for a disproportional number of deaths relative to the amount prescribed, says Dr. Webster (Table). “About one-third of deaths associated from opioid use are related to methadone in particular. The reasons for this are two-fold. First, patients may be taking too much medication or mixing it with unauthorized substances. And second, patients may be started on too much medication or dosing may be escalated too rapidly. These findings highlight the need for physician education on pain management with opioids as well as on the use of multimodal treatment approaches. Clinicians who prescribe opioids long term should intensify efforts to assess and monitor patients.”

According to Dr. Webster, physicians need to ensure that opioids are being given to the right patients under the appropriate circumstances and within the confines of set parameters to truly benefit patients. “Much of the risk associated with opioid use comes through patients making mistakes that put them at grave risk. Patients may be driven to misuse opioids by their desire for greater pain relief or to self-medicate comorbid mental health problems or other issues. To improve care, we need to be specific and write pain drug prescriptions with explicit directions. We also need to consider alternative agents in patients who don’t require opioids. These steps are critical to decreasing the potential for abuse and associated mortality risk in the future.”

References

American Pain Foundation. PainSAFE. Available at: http://www.painfoundation.org/painsafe/.

American Pain Foundation. Physician Perspective Toward Prescription Opioid Abuse and Misuse: Summary of Findings. Available at: http://www.painfoundation.org/media/resources/physician-survey-summary.pdf.

Special Issue: Deaths Related to Opioids Prescribed for Chronic Pain: Causes and Solutions. Pain Med. 2011;12(Suppl 2):S13-S92. Available at: http://onlinelibrary.wiley.com/doi/10.1111/pme.2011.12.issue-s2/issuetoc.

Webster LR, Cochella S, Dasgupta N, et al. An analysis of the root causes for opioid-related overdose deaths in the United States. Pain Med. 2011;12(Suppl 2):S26-S35.

Webster LR, Dasgupta N. Obtaining adequate data to determine causes of opioid-related overdose deaths. Pain Med. 2011;12(Suppl 2):S86-S92.