ACMT position statement on prescribing opioids: a missed opportunity

January 6, 2016, 11:26 pm


Safety Issues Regarding Prescription Opioids. American College of Medical Toxicology J Med Toxicol 2016 Jan 5 [Epub ahead of print]

No abstract available

This “Position Statement” from the American College of Medical Toxicology (ACMT) covers 3 topics related to safety issues associated with use of prescription opioids. Unfortunately, some of the positions taken by the College are, to say the least, wishy-washy, and represent a missed opportunity to make some important points forcefully.

The first topic addressed in this statement involves the use of medications that combine acetaminophen with an opioid such as hydrocodone (e.g., Vicodin.) This formulation never made any sense to me. Since the analgesic dose of acetaminophen is 1000 mg, and the acetaminophen-opioid preparations generally contain only 325 mg of acetaminophen, the patient would have to take at least 3 pills to get a therapeutic effect from the non-opioid component. In addition, as the position statement points out, patients who take more than the prescribed dose run the risk of acetaminophen-induced hepatotoxicity.

The statement recommends:

” . . . when prescribing opioids, a risk-benefit analysis for both acetaminophen toxicity and opioid muse should direct the choice of a combination analgesic.”

To my mind the combination product is all risk and no benefit. A stronger, more convincing, statement would recommend that combination products not be used at all. This was certainly a missed opportunity to advocate for the rational proposition that these products should not be used at all.

The second topic addressed concerns total daily opioid dose. The statement cites not surprising evidence that patients receiving higher daily doses of opioids (>50-100 mg morphine equivalent) are at greater risk of overdose than those receiving lower doses. Therefore, the College goes out on a limb by stating:

“It is the position of ACMT that providers always exercise caution when prescribing outpatient opioids especially in doses that exceed 50 mg daily (in morphine equivalents) . . .”

This suggests there are other situations where providers prescribing opioids or other medications do not have to exercise caution. On its face, the statement is meaningless.

Finally, the Position Statement addresses the topic of tamper-resistant and abuse-deterrent opioid formulations. Here the authors make some good points. They note that these deterrent measures have very limited effectiveness for several reasons:

  1. Although these measures can make it less likely the drug can be easily injected or snorted, they can be defeated.
  2. Much abuse of these drugs involves oral — not parenteral — administration.
  3. Often individuals who abuse these drugs will just move on to heroin.


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