When Opioids Almost Kill You, Chances Are You'll Get More Opioids

I really wanted the first post of 2016 to be positive, uplifting, inspiring... but a study I read over the break was so unnerving, I had to go and ruin "return to work" day, already a day that lives in infamy, with even more depressing news.

Researchers at Boston Medical Center used a national database of prescription information to assess the likelihood of continued opioid prescriptions after a non-fatal overdose.  They looked at prescription information from 3,000 patients who experienced a non-fatal overdose between 2000 and 2012.  These patients were all prescribed opioids for chronic, non-cancer pain. 

Think about this: These 3,000 patients have already overdosed on prescription opioids. They are lucky to be alive. Surely, their healthcare providers will find another way, another mechanism, another approach to managing their pain. The risk here isn't illness or infection or a change in blood pressure... it's death.  

The bad news:

• Over 90% of these patients continued to receive opioids after their non-fatal overdose event
• 50% of these continued to receive the prescriptions from the same doctor
• 7% of the original group experienced a second overdose
• Two years after the first overdose, those with continuing opioid prescriptions were twice as likely to experience a second overdose event compared to those who were no longer receiving opioids. 

Why is this is happening?  

First, our fragmented healthcare system doesn't make it easy for prescribing physicians to discover the clinical events experienced by their patients outside of their immediate purview.  And patients may not want to disclose an overdose event for fear of having their medications discontinued.  I get that.  And it makes we wonder whether PDMPs should also include the ability for inpatient settings to report both fatal and non-fatal overdose events to the database so doctors can see this information whether its reported by the patient or not.  Linking electronic health records to PDMP systems would be a good start down this path.    

The second phenomenon driving these sorry statistics is that doctors are not comfortable weaning opioid (and other) medications.  No one, least of all me, would ever suggest immediate cessation of opioid therapy in light of a non-fatal overdose.  That's clinically irresponsible and potentially dangerous for the patient.  But the necessary steps forward are complicated: If the patient is on multiple medications that require weaning, which should we weaned first?  What titration steps should be used?  Is medication-assisted-therapy (MAT) an option?  Should I refer the patient or try to handle this myself?  These are hard questions and the primary care community, by far the most frequent prescribers of opioids, is currently ill-equipped to handle them.

Welcome to 2016.  Once more unto the breach, dear friends.  

Michael 

On Twitter @PRIUM1  

1 in 4 Opioid Scripts Ends Up "Long Term"

The Mayo Clinic wanted to assess the risk factors associated with opioid use.  They started by asking, "How many opioid prescriptions end up leading to long term use?"

Turns out, 1 in 4.  

Specifically, the researchers found that 21% of first-time prescriptions led to use for 3-4 months and 6% of first-time scripts led to use longer than 4 months.

Those time intervals are silly, aren't they?  From our perspective in work comp, we're seeing material numbers of injured workers progress (or, perhaps, regress) to 3-4 years of opioid use after the first script.  Personally, I'd like to see a study that tests use patterns over much longer duration intervals.  I also suspect that the work comp population exhibits a higher "long term use conversion rate" than a randomly selected patient population.  System design tends to reward certain stakeholders for disability duration.

The research is also intriguing because it examined the specific risk factors that lead to long term use. Nicotine use and prior substance abuse issues were the top risk factors.  While this isn't necessarily surprising, we see scant evidence that these risk factors are being taken into account at the time of the first opioid script.  The best predictive models in our industry are certainly telling us that these patients are at higher risk, but if the prescribing doctors aren't taking this information seriously and using it to inform an alternative, non-opioid treatment plan... what's the use?

Faster, more focused interventions with prescribers will be key to preventing long term opioid use.

Michael
On Twitter @PRIUM1