Opiate Overdoses Occurring at Lower Doses, Among Non-Chronic Users

As policy makers, substance abuse prevention advocates, and care providers continue to try to stem an unprecedented tide of opiate overdoses nationally, a recent state study suggests that it may not just be chronic opiate users and those on high doses of pain medications that deserve all of the attention and concern. The study, published in Medical Care journal, analyzed opioid prescriptions and related poisonings in Washington State between 2006 and 2010 and found that only 44 percent of patients who overdosed on pain medications were chronic users and only 17 percent of patients had "yellow-flag" opioid doses that were high enough to be targeted by state prescribing guidelines. These findings, which fly in the face of common wisdom and previous research about the most at risk populations for opioid overdoses, may serve as a useful wake-up call if they prompt more rigorous guidelines and more individualized, careful monitoring of patients.

As the basis of the study, researchers looked at the prescription histories associated with 2,250 opioid overdoses occurring among 1,809 patients from 2006-2010. A total of 65 percent of overdoses were due to opioid medications other than methadone, often used to treat heroin addiction as well as pain issues. Interestingly, of the total number of patients overdosing, less than half were chronic users (those with more than a 90-day supply of prescribed opioid medications in the prior year), and only 17 percent of patients had a "yellow-flag” dosage level (a morphine-equivalent dose of more than 120 milligrams per day). Instead, almost three out of 10 (28%) were taking a relatively low opioid dose of just 50 mg per day. However, it was also found that sedatives were involved in roughly half of all the overdoses, suggesting special attention be paid to the way these drugs might be combined by many patients.

The new findings run contrary to earlier research on the subject which has fairly consistently shown that both fatal and nonfatal overdoses were more likely in chronic opioid users and those with higher prescribed opioid doses. And, while they do suggest that opiate overdose concerns should extend beyond the most frequent and high dose users, they may point to a piece of the puzzle that can be corrected through revised guidelines and appropriate interventions. "It may be prudent to revise guidelines to also address opioid poisonings occurring at relatively low prescribed doses and with acute and intermittent opioid use, in addition to chronic, high-dose use," said lead author Deborah Fulton-Kehoe, PhD, a research scientist in the Department of Environmental and Occupational Health Sciences at the University of Washington School of Public Health in Seattle.

In 2007, Washington adopted some of the toughest opioid prescribing regulations in the country as a measure to try to tackle a burgeoning problem.  And it seemed to work.  Nonfatal overdoses from prescription pain medications leveled off after introduction of the new guidelines, while nationally the numbers continued to rise. With the release of these new findings, many argue that prescribing guidelines need to be even more expansive in terms of the groups they target. Based on the recommendations of this and other studies, Washington State has taken new measures to caution doctors about prescribing opioids at any dose. The state’s new guidance extends to the treatment of acute pain, not just chronic pain.

It also emphasizes treatment versus simple pain relief. As such, physicians are advised to discontinue prescribing opioids to a patient if they don't show “clinically meaningful improvement” in physical function, in addition to pain management. While the overdose study focused on only one state, one expert says it has national and even global implications. “The article notes that many overdoses occur when patients are prescribed medications at low doses. This has important implications for national policy and debate,” said Dr. Jeroan Allison of University of Massachusetts Medical School, who is co-editor-in-chief of Medical Care. "The statistics are quite overwhelming and dramatic, and this problem affects every state in our nation." According to the Centers for Disease Control, more than 16,500 deaths in the U.S. were linked to opioid overdoses in 2010.