In the U.S., prescriptions for and sales of opioid painkillers have nearly quadrupled since 1999, according to the Centers for Disease Control and Prevention. Researchers from the University of Michigan Medical School and the Department of Veterans Affairs’ Ann Arbor Healthcare System published a new study in the online journal Medical Care exposing a major problem in prescribing these powerful drugs: The dosage may make the difference between life or death.
The researchers examined data from 221 veterans who died from accidental opioid painkiller overdoses compared to data from same number of similar patients who also took opioids for chronic pain but did not overdose.
According to the study results, the average dose prescribed to the overdose victims was much higher – on average, 71 percent higher – compared to the other group.
Mind the per-pill dose
In a press release from the University of Michigan, Amy Bohnert, MHS, Ph.D., VA/U-M, first author of the new study, explained:
“As the United States grapples with the rising toll of accidental overdoses due to opioids, our findings suggest that changing clinical practices to avoid escalating doses for patients with chronic pain could make a major difference in the number of patients who die.”
According to Bohnert, an epidemiologist who specializes in studying opioid use and abuse, keeping per-pill dosages low would protect not only patients, but others who may have illicit access to the drug, such as young people in the patients’ homes.
“Avoiding prescribing large doses also has the benefit of reducing the amount of the medications going to patients’ homes that has the potential to be taken by others who live with the patient, like children and teenagers,” Bohnert added. “This is important because an opioid that is a larger dose per pill, compared to a smaller one, is going to be deadly to a child or adult who hasn’t been taking the medication regularly.”
In the group of veterans studied for the UM paper, less than 25 percent of the non-overdosing veterans received prescriptions for daily doses above 50 MEM while 60 percent of those who overdosed were prescribed over 50 MEM per day. This dosage measurement is morphine milligram equivalents or MME, sometimes written as morphine-equivalent milligrams or MEM, which describes differences in the strength of various prescription opioid painkillers.
New CDC opioid prescription guidelines
Bohnert was also a member of the Core Expert Group charged by the CDC with the development of new guidelines for prescribing opioid painkillers. The new proposed CDC guidelines address:
- When to prescribe opioids for patients
- Determining proper dosage and duration
- When to conduct follow ups with patients
- Assessing the risk of abuse
- Discontinuing the prescription
- Addressing abuse or other harms from opioid use.
Overall the CDC gave 12 distinct recommendations including:
- Providers should look to other types of pain medications first. Non-opioid treatment for chronic pain is preferred unless it’s for cancer, palliative and end-of-life care.
- Physicians should discuss realistic treatment goals with patients, including pain levels and functioning.
- Physicians should prescribe immediate-release opioids instead of extended-release/long acting pills when beginning opioid therapy.
- If opioids are deemed necessary, the lowest effective dose should be used. Additional precautions should be put in place for any patient who receives more than 50 MEM per day. Prescriptions over 90 MEM daily should be avoided.
- Physicians should evaluate the benefits and harms related to opioid use with patients at least every 3 months.
- Clinicians should review the patient’s history with controlled substance prescriptions to determine the patient’s risk for abuse or overdose.
- Clinicians should use urine drug testing before starting and during opioid therapy to look for other prescribed medications or illicit drug use.
The CDC also created a checklist to help physicians determine if prescribing opioids is the best course of treatment.
“Determining whether opioid painkillers are appropriate for a patient and at what dosage is not an easy answer,” states Dr. Lousine Alpern. “In many situations our reviews have resulted in our patients being put on better regimens that have positively impacted patient care. We actively discuss through peer-to-peer calls with providers the alternatives available that can lead to better optimized pain regimens and stronger outcomes.”
To learn more about optimized care through review you can review our infographic from July 2015 titled “Opioids and Workers’ Comp – Optimize Care Through Review”.