The Poison Review

OPIOID PRESCRIPTIONS FOR CHRONIC PAIN AND OVERDOSE Dunn KM et al. Ann Intern Med 19 Jan 2010;152:85-92.

Abstract

Using the computerized database of the Group Health Cooperative in Washington state, the authors studied almost 10,000 patients who received opiate prescriptions for chronic noncancer pain. Their primary outcomes were the occurrence of diagnosed fatal and nonfatal overdoses.  They identified 51 opiate-related overdoses, 6 of which were fatal.  Not surprisingly, they found that the risk of overdose went up with increasing daily prescribed opiate dose. 

This was a large study: 11 authors, 8 years, 2 grants (National Institute of Drug Abuse, Wellcome Trust), lots of statistics.  Maybe it’s just me, but reading through their methods I found it hard to understand exactly what they did — a good sign that a study will be ultimately disappointing.  And after all this, what do the authors conclude:

” . . . long-term opioid therapy should be prescribed with awareness of risks and close patient monitoring . . .”

An accompanying editorial notes that the authors data show that many of the overdoses were in patients already at high risk for an adverse opiate-related event, including those with histories of substance abuse, sedative-hypnotic use, and depression.  Use of high-dose opiates — especially in these high-risk patients — requires considerable investment of the clinician’s time in educating and monitoring patients.  It is not realistic to expect that this will always occur in the current medical environment.  As the editorial states: “It is easy to suggest time-consuming, unreimbursed approaches to improve the safety of opioid prescribing without specifying how they can be incorporated into already overburdened clinical settings”.