Unintentional Overdose Deaths Associated With Nonmedical Use Of Prescription Pain Relievers

In 1997, two expert panels in the United States introduced clinical guidelines for management of chronic pain, including encouraging expanded use of opioid pain medications after careful patient evaluation and counseling when other treatments are inadequate. In the 10 years since the guidelines were first published, per capita retail purchases of the pain relievers methadone, hydrocodone, and oxycodone in the United States increased dramatically, according to background information in the article. Along with the increase in legitimate sales of opioids, rates of emergency department visits and deaths attributable to opioid analgesic overdoses have also increased.

Aron J. Hall, D.V.M., M.S.P.H., of the Centers for Disease Control and Prevention, Atlanta, and colleagues conducted a study to determine the risk characteristics and other factors associated with persons dying of unintentional pharmaceutical overdose in West Virginia in 2006. During 1999-2004, West Virginia experienced the nation's most substantial increase (550 percent) in death from unintentional poisoning. The researchers used data from medical examiner, prescription drug monitoring program, and opiate treatment program records.

Of 295 persons who died (decedents), 198 (67.1 percent) were men and 271 (91.9 percent) were age 18 through 54 years. Among all decedents, 63.1 percent had used pharmaceuticals that contributed to their death without documented prescriptions (i.e., diversion), and 21.4 percent had 5 or more clinicians prescribe them controlled substances in the year prior to death (i.e., doctor shopping). Women were significantly more likely to have evidence of doctor shopping than men (30.9 percent vs. 16.7 percent). Prevalence of diversion was greatest among the group age 18 through 24 years. Relative to all other age groups, the group age 35 through 44 years was associated with a significantly greater rate of doctor shopping (30.7 percent vs. 18.2 percent). Of the 295 persons who died, 94.6 percent had at least 1 indicator of substance abuse.

Compared with deaths involving prescribed pharmaceuticals, deaths involving diversion were associated with history of substance abuse, nonmedical route of pharmaceutical administration, and a contributory illicit drug. In contrast, decedents with evidence of doctor shopping were significantly more likely to have had a previous overdose and significantly less likely to have used contributory alcohol compared with decedents who had fewer than 5 clinicians prescribe them controlled substances in the year prior to death.

Multiple contributory substances were implicated in 234 deaths (79.3 percent). Opioid analgesics were the most prevalent class of drugs, contributing to 93.2 percent of deaths; of these, only 44.4 percent included evidence of prescription documentation for all of the contributory opioids. The most common drug identified was methadone, which was involved in 40 percent of all deaths. The percentage of decedents with valid prescriptions for methadone was lower than the percentage of those with valid prescriptions for hydrocodone or oxycodone.

"Clinicians have a critical role to play in preventing the diversion of prescription drugs. Clinicians and pharmacists need to counsel patients who are prescribed opioids not only about the risk of overdose to themselves but also about the risk to others with whom they might share their medication. In addition, clinicians should follow recent published guidelines for the management of chronic pain and refer patients as needed to pain management specialists. Clinicians should also make use of state prescription drug monitoring programs to determine whether their patients are getting scheduled drugs from other clinicians. Clinicians can now obtain such information about their patients from prescription drug monitoring programs in most states," the authors write.

Editorial: Prescription Opioids, Overdose Deaths, and Physician Responsibility

In an accompanying editorial, A. Thomas McLellan, Ph.D., of the Treatment Research Institute, and Barbara Turner, M.D., Ms.Ed., of the University of Pennsylvania School of Medicine, Philadelphia, write that there are steps physicians can take to help reduce the likelihood of prescription diversion.

"When deciding whether to prescribe an opioid, physicians should ask patients about their prior and current histories of alcohol and other drug use. Patients with histories of substance use, mental health problems, or both should receive special attention and co-management from pain management specialists when possible. Treatment of mental health disorders should be considered part of successful pain management."

"Physicians also should consider an opioid treatment agreement (contract) with the patient stipulating the frequency of obtaining medications, timely refills but no early replacements for lost prescriptions, safe storage, no sharing, single-source prescribing, monitoring through urine screens, and adherence to monitoring visits. The agreement should be presented as a way of simultaneously protecting the patient from adverse events and promoting a collaborative, responsible relationship."