In an examination of unintentional overdose deaths in the state of West Virginia, a majority of these have been found to be associated with the nonmedical use and diversion of prescription drugs, especially pain relievers, according to an article released on December 9, 2008 in JAMA.
In the management of chronic pain, guidelines were introduced in 1997 encouraging the expanded use of opioid pain relievers, pending stringent patient evaluation and full counseling, if other treatments are inadequate. Since then, the retail purchases of just such analgesics, including methadone, hydrocodone, and oxycodone, increased enormously, according to the article. This was accompanied by a parallel increase in emergency department visits and deaths attributed to opioid pain reliever overdoses. According to the article, West Virginia has suffered one of the highest increases in these types of deaths in the United States, having a 550% increase in death from unintentional poisoning between 1999 and 2004.
Of the 295 who died, 67.1% (198) were men, and 91.9% (271) were between the ages of 18 and 54. Of the deceased, 63.1% had used pharmaceuticals which contributed to death without documented prescriptions, and 21.4% had received prescriptions from five or more clinicians in the previous year. Women were more likely to have “shopped” for multiple clinicians than men, with 30.9% of them performing this act while only 16.7% of men did. Meanwhile, use of the drugs without documented prescriptions was more common for those two died between 18 and 24 years of age. Of the total population, 94.6% had at least one indicator of substance abuse.
Deaths related to illegal prescription use were often associated with a history of substance abuse, nonmedical pharmaceutical administration, and illicit drugs. Deaths with prescriptions from multiple doctors were more likely to have had previous overdoses, and less likely to have alcohol contributing to death.
Of the total, 79.3% (234) of deaths were linked to multiple contributory substances. The most prevalent class of drugs was the opioid analgesics, contributing to 93.2% of deaths, and of these, 44.4% showed evidence of prescription documentation. Methadone was the most commonly identified drug, and it was involved in 40% of all of the deaths. Fewer of the deceased had prescriptions for methadone than for other drugs such as hydrocodone or oxycodone.
The authors note the important role of doctors themselves in the use of prescription opioids. “Clinicians have a critical role to play in preventing the diversion of prescription drugs. Clinicians and pharmacists need to counsel patients who are prescribed opioids not only about the risk of overdose to themselves but also about the risk to others with whom they might share their medication. In addition, clinicians should follow recent published guidelines for the management of chronic pain and refer patients as needed to pain management specialists. Clinicians should also make use of state prescription drug monitoring programs to determine whether their patients are getting scheduled drugs from other clinicians. Clinicians can now obtain such information about their patients from prescription drug monitoring programs in most states,” they write.
A. Thomas McLellan, Ph.D., of the Treatment Research Institute, and Barbara Turner, M.D., Ms.Ed., of the University of Pennsylvania School of Medicine, Philadelphia, contributed an accompanying editorial in which they state several steps physicians should take to help reduce the likelihood of inappropriate prescription opioid use.
“When deciding whether to prescribe an opioid, physicians should ask patients about their prior and current histories of alcohol and other drug use. Patients with histories of substance use, mental health problems, or both should receive special attention and co-management from pain management specialists when possible. Treatment of mental health disorders should be considered part of successful pain management.”
“Physicians also should consider an opioid treatment agreement (contract) with the patient stipulating the frequency of obtaining medications, timely refills but no early replacements for lost prescriptions, safe storage, no sharing, single-source prescribing, monitoring through urine screens, and adherence to monitoring visits. The agreement should be presented as a way of simultaneously protecting the patient from adverse events and promoting a collaborative, responsible relationship,” they write.
Patterns of Abuse Among Unintentional Pharmaceutical Overdose Fatalities
Aron J. Hall, DVM, MSPH; Joseph E. Logan, PhD; Robin L. Toblin, PhD, MPH; James A. Kaplan, MD; James C. Kraner, PhD; Danae Bixler, MD, MPH; Alex E. Crosby, MD, MPH; Leonard J. Paulozzi, MD, MPH
JAMA. 2008;300(22):2613-2620.
Prescription Opioids, Overdose Deaths, and Physician Responsibility
A. Thomas McLellan, PhD; Barbara Turner, MD, MsEd
JAMA. 2008;300(22):2672-2673.
For more information on what opioids are, and opioid-induced constipation (OIC), please see:
All About Opioids and Opioid-Induced Constipation (OIC)
Written by Anna Sophia McKenney