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 “We found the results both surprising and concerning,” said lead
author Dr. Marc R. Larochelle of Boston Medical Center.
“While this study wasn't designed to answer why, one possibility is
that providers are not aware that their patients experienced an
overdose when making the decision to continue prescribing opioids,”
Larochelle told Reuters Health by email. “This lack of knowledge may
be a symptom of our fragmented health care system where there is no
clear mechanism to communicate events from emergency department or
inpatient settings to providers in the community.”
The researchers used Optum, a national commercial insurance claims
database, to identify almost 3,000 patients who experienced a
nonfatal overdose between 2000 and 2012 while taking long-term
opioids prescribed for chronic pain not related to cancer. Opioids
include drugs like codeine, oxycodone, hydrocodone, hydromorphone,
and tramadol.
Just over 90% of these patients continued to receive prescription
opioids after the overdose. More than half got the prescription from
the same doctor.
Past providers could theoretically be identified through
prescription monitoring programs or insurance claims data and
notified of an overdose, but there is no way to notify other
providers, Larochelle said.
There were 212 second overdoses, 7% of the original group.
Two years after the first overdose, those who still had a
prescription for the drugs were twice as likely to have experienced
a second overdose than those whose prescriptions were stopped, the
researchers reported online December 28 in Annals of Internal
Medicine.
Repeated overdose risk was highest for patients receiving the
highest dosages of the drugs.
Prescribers probably don’t know when a patient overdoses, said Dr.
Jessica Gregg of Central City Concern in Portland, Oregon, who wrote
an editorial accompanying the new results.
“There are no widespread systems in place, either within health
plans or through governmental organizations, for notifying providers
when overdoses occur,” Gregg told Reuters Health by email.
Overdoses often happen when patients take too much of an opioid or
when they take them in conjunction with other medications, like
benzodiazepines, or with alcohol, she said.
“Patients who have misused their prescriptions are unlikely to
report that misuse (and their subsequent overdose) to their
prescriber out of concern that the provider will terminate their
prescriptions,” Gregg said.
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In addition, most physicians receive little training and have few
resources to address chronic pain, so opioids are one of few
options, she said.
“After an overdose, a provider can terminate the prescription,
knowing that his or her patient will suffer withdrawal and may turn
to illicit opioids for relief, or the provider can continue the
prescription, knowing that that medication may ultimately do more
harm than good,” Gregg said.
Rather than stopping a prescription after an overdose, the
medication should be tapered off gradually, since long-time users
can experience severe withdrawal symptoms otherwise, she said.
“There is very little evidence that long-term opioids are effective
for chronic pain,” Gregg said.
Eight percent of those whose prescriptions were stopped went on to
have another overdose in the next two years, which is lower than
those who continued to have a prescription, but still concerning,
Larochelle said.
“Stopping opioids alone is not a solution,” he said. “In addition to
treatment of any potential opioid use disorder, we need to
communicate alternative options for treatment of chronic pain, and
all modalities should be considered, including non-opioid
medications, physical therapy, and complementary and alternative
treatments.”
“In a perfect world, a physician would be able to work with a team
that might include physical therapists and/or occupational
therapists, alcohol and drug counselors, and individuals with
expertise in understanding and treating the links among experiences,
emotions, and pain,” Gregg said. “That team could develop a
personalized treatment plan that would likely be far more effective
than prescription opioids.”
SOURCE: http://bit.ly/1QSN5ws and http://bit.ly/1ZxYYck
Ann Intern Med 2015.
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