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Opioids — also known as opiates or narcotics — are among the most overprescribed drugs in the U.S. The Centers for Disease Control and Prevention (CDC) reported that in 2010, enough opioid or narcotic pain drugs were prescribed to medicate every adult American, around the clock, for a month.[1]
The overprescribing of opioids has been a major contributing factor in an epidemic of drug addiction and overdose injuries and deaths over the past two decades. For 2013, the CDC estimated that...
Opioids — also known as opiates or narcotics — are among the most overprescribed drugs in the U.S. The Centers for Disease Control and Prevention (CDC) reported that in 2010, enough opioid or narcotic pain drugs were prescribed to medicate every adult American, around the clock, for a month.[1]
The overprescribing of opioids has been a major contributing factor in an epidemic of drug addiction and overdose injuries and deaths over the past two decades. For 2013, the CDC estimated that an average of 44 people in the U.S. died each day from an overdose of prescription opioids.[2] Although a large proportion of opioid-related injuries and deaths result from individuals misusing the drugs for nonmedical purposes (for example, to get high), many occur in patients who are prescribed opioids for management of acute or chronic pain.
To ensure the safe use of opioids, health care providers and patients need to understand the risk factors for opioid overdoses. A recent JAMA Internal Medicine study provides the first evidence suggesting that long-acting opioids are associated with a higher risk of unintentional overdoses than short-acting forms of these drugs.
Opioid overview
Opioids directly affect the central nervous system, producing pain relief and drowsiness. They are prescribed most commonly to relieve pain but also are used to treat cough and diarrhea and to cause drowsiness before an operation (see table, below, for examples of available opioids). These drugs, while undoubtedly effective, can be addictive and are associated with many adverse effects (see box, below). However, for patients with pain associated with a terminal illness, most notably the intractable pain of cancer, the risks with longer-term use become more acceptable.
| Common Adverse Effects of Opioids | |
|---|---|
|
|
Examples of Available Opioid Medications
|
Opioid active ingredient* |
Brand name(s) |
|---|---|
| butorphanol | Available in generic form only |
| codeine | TYLENOL WITH CODEINE |
| fentanyl | ABSTRAL, ACTIQ, DURAGESIC, FENTORA, IONSYS, LAZANDA, SUBSYS |
| hydrocodone | ANEXSIA, HYSINGLA, NORCO, VICOPROFEN, ZOHYDRO ER** |
| hydromorphone | DILAUDID, EXALGO |
| meperidine | DEMEROL |
| morphine | AVINZA, KADIAN, MS CONTINAVINZA, KADIAN, MS CONTIN |
| oxycodone | OXAYDO, OXYCET, OXYCONTIN, PERCOCET, PERCODAN, XARTEMIS XR |
| oxymorphone | OPANA, OPANA ER |
| pentazocine | Available in generic form only |
*Other active ingredients may be present in these products. Only opioid ingredients are listed.
** Do Not Use
Older adults may require less than the usual adult dose due to their bodies' greater sensitivity to opioid drugs, partly because the drugs are not metabolized or excreted by the kidneys as easily as in younger patients.
Opioid overdose
Patients experiencing an opioid overdose typically have three classic signs: pinpoint pupils, unconsciousness and respiratory depression (shallow and less frequent breaths)[3] due to the drugs’ effect on the parts of the brain that control breathing. With severe respiratory depression, breathing can stop completely, leading to death. Patients prescribed higher doses of opioids are at greater risk of an overdose.[4] Risk also increases when opioids are combined with alcohol and other central nervous system depressants, particularly sedatives, sleeping pills and tranquilizers.
It has been unclear whether the risk of unintentional overdose differs between long-acting and short-acting opioids. The JAMA Internal Medicine study, published in April, provides initial information that may help answer this question.
New study findings[5]
A team of researchers based in Boston, using funding from the CDC, examined the relationship between opioid use and nonfatal, unintentional overdose in patients receiving care within the Department of Veterans Affairs health care system (VA). Using national VA medical and pharmacy records, the researchers identified all VA patients who had been started on a single opioid for treatment of chronic noncancer pain from 2000 through 2009 (approximately 821,000 patients).
Among the types of chronic pain treated in these patients were headache, back and neck pain, arthritis, other types of joint problems, and pain from nerve damage. The majority of the study patients — 98 percent — were prescribed a short-acting opioid. The other 2 percent received a long-acting drug.
The researchers found that a total of 319 unintentional overdoses occurred during the study period: 282 in patients treated with short-acting opioids and 37 among those prescribed a long-acting drug. Approximately half of these overdoses happened within the first two months of beginning opioids.
After taking into account age, sex, opioid dose and other patient characteristics, the researchers found that patients treated with long-acting opioids were more than twice as likely to have suffered an unintentional overdose as patients who received a short-acting opioid. The difference in risk between the two groups was most marked during the first two weeks following initial prescription of an opioid, when the chances of an overdose were more than five times higher in the patients treated with a long-acting opioid.
While further studies will be needed to provide a definitive answer, these results suggest that long-acting opioids pose a greater risk of unintentional overdose than short-acting opioids.
What You Can Do
If you need to take an opioid for pain, always use the lowest dose for the shortest time needed to achieve adequate relief. Also ask your doctor to prescribe a short-acting opioid whenever feasible.
Opioids have not been proven to be a safe and effective treatment for chronic noncancer pain.[6] In fact, there is substantial evidence that the risks of opioids for chronic noncancer pain outweigh their benefits. Therefore, you should limit use of opioids to no more than 90 days. If you need pain management beyond 90 days and have noncancer pain, discuss non-opioid options with your doctor and consider consulting a pain management specialist.
When you or a loved one starts taking an opioid, be alert for early signs of an overdose or other severe adverse events, especially during the first few weeks. If a loved one experiences signs of an overdose,seek emergency medical care immediately.
References
[1] Centers for Disease Control and Prevention. Prescription painkiller overdoses in the US. CDC Vitalsigns. November 2011. http://www.cdc.gov/vitalsigns/PainkillerOverdoses/index.html. Accessed September 17, 2015.
[2] Centers for Disease Control and Prevention. Prescription drug overdose data: Death from prescription opioid overdose. http://www.cdc.gov/drugoverdose/data/overdose.html. Accessed September 17, 2015.
[3] World Health Organization. Management of substance abuse: Information sheet on opioid overdose. November 2014. http://www.who.int/substance_abuse/information-sheet/en/. Accessed September 17, 2015.
[4] Dunn KM, Saunders KW, Rutter CM, et al. Opioid prescriptions for chronic pain and overdose: A cohort study. Ann Intern Med. 2010;152(2):85-92.
[5] Miller M, Barber CW, Leatherman S, et al. Prescription opioid duration of action and the risk of unintentional overdose Among Patients receiving opioid therapy. JAMA Intern Med. 2015;175(4):608-615.
[6] Physicians for Responsible Opioid Prescribing. Petition to the Food and Drug Administration requesting changes to opioid drug product labeling. July 25, 2012. http://www.citizen.org/documents/2048.pdf. Accessed September 19, 2015.
